What should be documented when noting informed consent and capacity?

• A. The client's signature.
• B. Only the date of consent.
• C. The client's understanding, decision-making ability, and any limitations; capture accommodations or support provided.
• D. No documentation is needed.

Answer: (C)

When noting informed consent and capacity, you document the client’s actual understanding, their decision-making ability at the moment, and any factors that limit that ability; you also record any accommodations or support provided to help them understand. This shows that the client truly understood the information, could weigh options, and chose voluntarily, rather than simply signing something. Include what the client understood about the service, the options presented, and the risks and benefits, plus how they explained their decision. Note any limitations to capacity—such as language barriers, cognitive or mental health factors, or emotional distress—and what adaptations were made to address those barriers (interpreter services, plain-language materials, teach-back methods, extra time, or supportive supports). This creates a complete, defensible record that consent was truly informed and voluntary. Signing or dating alone doesn’t demonstrate understanding or capacity, and documenting nothing at all isn’t acceptable.