MCA resource - record keeping
What and when to record will vary. As a general rule, there is no need to record assessments of capacity to take day-to-day decisions. Remember in order to have protection from liability when providing care or treatment, carers must have a reasonable belief that the person they care for lacks capacity to make relevant decisions about their care or treatment (see section 5 (1) MCA).
In these circumstances, it is useful to be able to describe the steps taken and have a written record.
Professionals are subject to higher standards in terms of record keeping and a formal record will be required to be kept, for example in the patient’s clinical notes if a doctor or a healthcare professional is proposing treatment for someone who lacks capacity.
