Browse categories and answer follow-up questions to refine your symptom profile.
History
Capacity question and decision
Decision specific capacity context
Decision at hand
Proposed options
Time sensitivity
Consequences of accepting
Consequences of refusing
Baseline and trajectory
Baseline cognitive and functional status
Baseline orientation and memory
Prior capacity concerns
Prior similar presentations
Baseline supports and supervision
Symptoms and precipitants
Precipitants of possible incapacity
Acute intoxication or withdrawal
Delirium triggers
Acute psychosis or mania symptoms
Severe pain or distress
Sleep deprivation
Hypoglycemia risk
Communication and comprehension
Communication factors affecting assessment
Primary language
Hearing or vision impairment
Literacy and health literacy
Aphasia or dysarthria
Need for interpreter
Prior expressed wishes
Previously expressed values and preferences
Advance directive or prior capable wishes
Consistency of current choice with prior statements
Cultural and religious considerations
Alarm Features
Immediate threats and instability
Physiologic instability suggesting inability to safely decide
Hypoxia
Hypotension
Severe tachycardia
Fever with altered mental status
Recurrent seizures
Neuro and cognitive red flags
High risk neurologic features
New focal neurologic deficit
New confusion or fluctuating attention
Reduced level of consciousness
Severe headache with new mental status change
Behavioral safety red flags
Safety risks requiring immediate containment
Threats of violence
Severe agitation with inability to redirect
Inability to maintain basic self care
Unsafe wandering or elopement risk
Legal and ethical escalation triggers
High risk refusal scenarios
Refusal of life saving therapy
Refusal with evidence of delirium or intoxication
Refusal with new psychosis symptoms
Refusal with inability to state a stable choice
Medications
Medication contributors to incapacity
High risk medication classes
Opioids
Benzodiazepines
Anticholinergics
Sedative hypnotics
Antipsychotics
Polypharmacy
Recent medication changes
Recent changes affecting cognition
New medication starts
Dose escalations
Missed doses
Withdrawal risk medications
Antidotes and reversal considerations
Reversal options if clinically indicated and protocol aligned
Naloxone for opioid toxicity
Dextrose for hypoglycemia
Thiamine before glucose when malnutrition risk
Agitation management examples
Sedation options if safety risk and local protocol dependent
Haloperidol IM 2 mg
Haloperidol IM 5 mg
Lorazepam IM 1 mg
Lorazepam IM 2 mg
Olanzapine IM 5 mg
Olanzapine IM 10 mg
Diet
Intake and metabolic risk
Nutrition and hydration patterns
Poor oral intake
Dehydration risk
Vomiting or diarrhea losses
Substance exposure through diet
Exposures affecting cognition
Caffeine excess
Energy drink use
Cannabis edibles
Alcohol exposure
Alcohol use pattern when relevant
Last drink timing
Daily use pattern
Withdrawal risk window
Review of Systems
Neurologic and cognitive
Neuro cognitive symptoms
Confusion
Inattention
Memory impairment
New headache
Seizure activity
Psychiatric and behavioral
Behavioral symptoms
Hallucinations
Delusions
Disorganized thinking
Severe anxiety or panic
Agitation
Infectious and systemic
Systemic symptoms
Fever
Chills
Recent infection symptoms
Weight loss
Cardiopulmonary contributors
Cardiopulmonary symptoms
Chest pain
Dyspnea
Palpitations
Syncope
Collateral History and Family History
Collateral source and reliability
Collateral information
Source identity
Relationship to patient
Time with patient recently
Reliability concerns
Baseline cognition and function collateral
Baseline comparison
Known dementia or neurocognitive disorder (F03.90)
Developmental disorder history (F89)
Baseline independence level
Family history relevant to capacity drivers
Heritable conditions affecting cognition
Early onset dementia family history
Major psychiatric illness family history
Seizure disorder family history (G40.909)
Social supports and supervision
Support network
Responsible adult availability
Housing stability
Caregiver capacity and willingness
Risk Factors
Medical risks for delirium and impaired decision making
Delirium risks
Older age
Known dementia (F03.90)
Infection risk
Polypharmacy
Renal failure risk (N18.9)
Substance related risks
Substance risks
Alcohol use disorder (F10.20)
Opioid use disorder (F11.20)
Stimulant use disorder (F15.20)
Sedative hypnotic use disorder (F13.20)
Situational risks for unsafe discharge
Disposition risks
Homelessness
Lack of phone or transportation
No safe place to stay
No ability to obtain medications
Vulnerable populations
Special populations
Pregnancy
Pediatrics and assent considerations
Intellectual disability
Language barriers without interpreter access
Differential Diagnosis
Life threatening
Life threatening causes of impaired capacity
Hypoxia (R09.02)
Hypoglycemia (E16.2)
Sepsis (A41.9)
Intracranial hemorrhage (I62.9)
Stroke (I63.9)
Meningitis or encephalitis (G03.9)
Toxidrome
Severe alcohol withdrawal (F10.239)
Common
Common causes of impaired decision making
Delirium (R41.0)
Intoxication
Medication adverse effect
Major depressive disorder with cognitive impairment (F32.9)
Acute psychosis (F29)
Mania or hypomania (F31.9)
Less common
Less common causes
Thyroid dysfunction (E03.9)
Hepatic encephalopathy (K72.90)
Uremic encephalopathy (N18.9)
Nonconvulsive status epilepticus (G41.90)
Wernicke encephalopathy (E51.2)
Mimics and pitfalls
Mimics and interpretation traps
Cultural disagreement misread as incapacity
Language barrier misread as incapacity
Pain and fear limiting engagement
Sedation effect during evaluation
Past Medical History
Neurocognitive and neurologic conditions
Neuro history
Dementia (F03.90)
Prior stroke (I63.9)
Seizure disorder (G40.909)
Traumatic brain injury history (S06.9X0A)
Psychiatric history
Mental health history
Schizophrenia spectrum disorder (F20.9)
Bipolar disorder (F31.9)
Major depressive disorder (F32.9)
Anxiety disorder (F41.9)
Substance use history
Substance use disorders
Alcohol use disorder (F10.20)
Opioid use disorder (F11.20)
Stimulant use disorder (F15.20)
Functional baseline and prior dispositions
Prior baseline and prior episodes
Baseline activities of daily living independence
Prior involuntary holds or capacity findings
Prior adverse outcomes after discharge
Physical Exam
General and vital signs
General appearance and physiologic status
Level of consciousness
Respiratory effort
Signs of intoxication
Signs of withdrawal
Temperature pattern
Neurologic
Neurologic exam
Orientation
Attention testing
Speech and language
Cranial nerves
Motor and sensory asymmetry
Gait if safe
Mental status and capacity elements
Mental status exam aligned to capacity domains
Understanding of information
Appreciation of consequences
Reasoning about options
Ability to express a stable choice
Cardiopulmonary
Heart and lung findings
Hypoxia signs
Arrhythmia clues
Heart failure signs
Toxidrome and metabolic clues
Targeted tox and metabolic exam
Pupils and diaphoresis
Tremor and hyperreflexia
Nystagmus
Track marks
Asterixis
Lab Studies
Core labs for reversible causes
Screening labs when altered cognition suspected
Glucose point of care
Electrolytes including sodium
Renal function
Liver enzymes
CBC
TSH when clinically indicated
Toxicology testing
Substance testing when results change management
Blood ethanol
Urine drug screen limitations
Acetaminophen level with unclear ingestion history
Salicylate level with concerning symptoms
Infection evaluation
Infection workup when suspected
Lactate
Blood cultures before antibiotics when septic shock concern
Urinalysis
Viral testing local protocol dependent
Interpretation pitfalls
Common lab pitfalls
Normal labs do not exclude delirium
Positive tox screen does not prove incapacity
Negative tox screen does not exclude intoxication
Imaging
Scoring Systems
Decision supports relevant to disposition and risk
Delirium screening tools local protocol dependent
Withdrawal severity scales local protocol dependent
Capacity is clinical and decision specific
MRI
MRI considerations for impaired cognition
Indications focal neurologic deficit with non diagnostic CT
Contraindications implanted ferromagnetic devices
CT
CT considerations for impaired cognition
Noncontrast CT head for trauma or new focal deficit
Radiation risk and pregnancy considerations
Ultrasound
Ultrasound and POCUS
Bladder scan for urinary retention delirium trigger
Cardiac and lung POCUS for hypoxia or shock phenotype
Special Tests
Bedside cognitive and delirium screening
Brief bedside tools
Attention testing
Orientation testing
Short term recall testing
Delirium screening local protocol dependent
Capacity interview structure
Capacity domains in structured interview
Understanding teach back
Appreciation of personal impact
Reasoning comparison of options
Choice consistency over time
Neurologic bedside maneuvers
Focused bedside tests
Finger to nose and heel to shin
Pronator drift
Romberg if safe
Substance withdrawal assessment
Withdrawal assessment when suspected
Tremor severity
Autonomic hyperactivity signs
Time since last use
ECG
Indications
ECG indications in capacity affecting presentations
Stimulant intoxication concerns
Syncope or near syncope
Chest pain or dyspnea
Antipsychotic use with QT risk
High risk patterns
ECG red flags
Prolonged QTc
Wide QRS
Brugada pattern concern
Ischemic changes
Serial ECG logic
Serial ECG approach when clinically indicated
Repeat with evolving symptoms
Repeat after correction of electrolytes
Assessment
Capacity determination framework
Core capacity principles
Decision specific
Time specific
Presumption of capacity unless evidence otherwise
Supportive measures before concluding incapacity
Capacity domains synthesis
Domain based conclusion
Understanding adequate or inadequate
Appreciation adequate or inadequate
Reasoning adequate or inadequate
Choice stable and communicable or not
Reversible causes and treatable drivers
Potential reversible contributors
Delirium (R41.0)
Intoxication
Hypoglycemia (E16.2)
Hypoxia (R09.02)
Infection (A41.9)
Risk and benefit weighting
Threshold for capacity rigor increases with risk
Low risk decisions
High risk refusal
High risk discharge decision
Plan
Support decision making and re evaluate
Measures to optimize capacity before final decision
Treat pain
Correct hypoxia
Correct hypoglycemia
Rehydrate if dehydrated
Reduce environmental stimulation
Interpreter use when needed
Treat underlying medical drivers
Medical stabilization priorities
Sepsis pathway if suspected local protocol dependent
Withdrawal treatment if indicated local protocol dependent
Delirium bundle local protocol dependent
Safety and behavioral management
Safety measures
De escalation and least restrictive approach
1 to 1 observation when needed
Physical restraint local protocol dependent
Chemical restraint local protocol dependent
Documentation essentials
Documentation elements for defensible capacity determination
Exact decision and alternatives explained
Patient statements demonstrating understanding and reasoning
Evidence of impairment
Steps taken to optimize capacity
Collateral input and reliability
Discussion of risks and benefits
Consultation plan
Consultation triggers
Psychiatry for complex psychosis or mania
Neurology for suspected stroke or seizure
Social work for safe discharge supports
Ethics or legal counsel local protocol dependent
Disposition
Discharge criteria
Discharge acceptable when all criteria met
Capacity for discharge decision present
Medical stability
No imminent safety risk
Safe destination confirmed
Reliable supervision when needed
Ability to obtain food, shelter, and medications
Observation or admission criteria
Higher level of care when criteria present
Delirium with unsafe function (R41.0)
Persistent intoxication impairing capacity
Unstable vitals or hypoxia
Need for serial exams or monitoring
No safe discharge plan
Involuntary hold and substitute decision making
Legal pathways local protocol dependent
Emergency hold criteria
Substitute decision maker identification
Best interests standard when incapable
Least restrictive alternative principle
Against medical advice pathway
AMA discharge workflow when capacity present
Specific risks of leaving reviewed
Return precautions provided
Harm reduction measures offered within scope
Follow up arranged when possible
Transfer criteria
Transfer to higher capability service
Need for inpatient psychiatry bed
Need for ICU monitoring
Need for neurologic intervention
Discharge Instructions
Copy discharge instructions
Plain language summary
Today you were evaluated for your ability to make medical decisions and for medical causes that can affect thinking
Your condition appears stable enough for you to leave based on the assessment today
Safety and supervision
Do not drive or operate machinery today
Have a responsible adult stay with you for the next day if available
Medications and substances
Avoid alcohol and non prescribed substances
Take prescribed medications only as directed
Follow up
Primary care follow up within 2 to 3 days
Return earlier if symptoms worsen
Return to emergency criteria
New or worsening confusion
Trouble breathing
Chest pain
Fainting
New weakness or trouble speaking
Fever with worsening mental status
Feeling unsafe at home
References
Guidelines and core sources
Capacity and consent references
American Medical Association Code of Medical Ethics Informed consent and decision making capacity
American College of Emergency Physicians Ethics Committee resources on refusal of treatment and capacity
American Psychiatric Association resources on assessment of decision making capacity
National Institute for Health and Care Excellence Delirium guideline 2023
World Health Organization mhGAP Intervention Guide latest update local protocol dependent
Project file reference
Evidence based clinical reference generator instructions
Formatting and structure constraints
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.