Which information should be documented for a patient who requires medical decision-making assistance?

• A. The last time witnessed without deficit, along with a name and telephone contact number for a relative.
• B. The patient’s favorite color and dietary preferences.
• C. The date of last hospitalization and primary care physician’s name.
• D. The patient’s blood type and vaccination history.

Answer: (A)

When a patient needs help making medical decisions, it’s crucial to document both their recent ability to decide and who can assist or act as a surrogate. Noting the last time the patient made a decision without deficits shows a baseline of decision-making capacity and helps clinicians gauge whether current capacity may be impaired. Including the name and telephone contact for a relative provides a clear surrogate contact who can participate in decisions or grant consent when the patient can’t, ensuring decisions align with the patient’s wishes and with any existing advance directives or power of attorney arrangements.

Other items like personal preferences or unrelated medical history don’t directly address who should be involved in decision-making or demonstrate capacity, so they’re not as relevant for this purpose.