Fillable MEDICAL REPORT TEMPLATE GUARDIANSHIP LIST (Department of Infrastructure, Transport, Cities and Regional Development)

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MEDICAL REPORT TEMPLATE GUARDIANSHIP LIST (Department of Infrastructure, Transport, Cities and Regional Development)

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MEDICAL REPORT TEMPLATE
GUARDIANSHIP LIST
ABOUT VCAT
The Victorian Civil and Administrative Tribunal (VCAT) hears and decides civil and administrative legal
cases in Victoria.
We make legal orders for matters about medical treatment, advance care directives, guardianship,
administration and powers of attorney. For more information, go to www.vcat.vic.gov.au/guardianship.
We rely on evidence, reports from experts and other supporting documents to help us reach a
decision about a case. This includes reports from medical practitioners.
WHAT VCAT CAN DO
We can give advice or make orders about medical treatment
VCAT can give advice or make orders about advance care directives, medical treatment decisions,
appointed medical treatment decision makers, appointed support persons and medical research
procedures.
If a person made an advance care directive, appointed a medical treatment decision maker or appointed
a support person, VCAT can decide whether their decision is valid or otherwise cancel, change or
suspend the advance care directive or the appointment. VCAT can do this only if we confirm whether
the person’s decision-making capacity is affected.
We can appoint a guardian or administrator
VCAT can make orders protecting adults who have a disability affecting their decision making capacity.
The disability may be a neurological impairment, intellectual impairment, mental disorder, brain injury,
physical disability or dementia.
If necessary, VCAT may appoint a guardian for people unable to make reasoned decisions about their
lifestyle, including health care, employment and living arrangements. VCAT may appoint an
administrator for people unable to make reasoned decisions about their financial and property affairs.
How we assess if a person has decision-making capacity
A person has decision-making capacity when they can do all of the following:
• understand and remember information relevant to making a decision
• retain that information to the extent necessary to make the decision
• use or weigh that information as part of their decision-making process
• use and communicate the information to make a decision, express their views and needs.
We can make an order about an enduring power of attorney
VCAT also has power to make orders about an enduring power of attorney. An enduring power of
attorney is a document allowing a person to appoint someone as their attorney to make decisions on
their behalf or support them in making decisions. The attorney can manage specific financial and legal
GPO Box 13193 Law Courts VIC 8010 Website www.vcat.vic.gov.au Phone 1300 01 8228
Ausdoc DX 210613 Melbourne Email humanrights@vcat.vic.gov.au
matters on behalf of the person. This arrangement stays in place even if the person who made the
appointment loses their decision-making capacity.
If a person has given an enduring power of attorney, VCAT has the power to revoke, vary or suspend
the appointment of an attorney if it considers it is in the person’s best interests to do so. VCAT does not
have the power to appoint an individual as an attorney.
How we assess if a person is a capable of giving an enduring power of attorney
A person is considered capable of giving an enduring power of attorney to someone if, at the time
they give it, they understand:
• they can set the conditions, instructions or limitations on the power of attorney
• when this power can be used
• the attorney can use their power even when the person who gave it temporarily or
permanently loses the ability to fully understand or make reasoned decisions
• they may revoke the enduring power of attorney at any time while they still understand the
nature and effect of this power
• the attorney’s power continues even if the person who gave it later loses their legal capacity
• at any time they are not capable of revoking the enduring power of attorney, they are unable to
effectively oversee the use of this power.
WHY WE NEED A MEDICAL REPORT
To give advice or make an order about medical treatment
Before making an order about a person, VCAT must be satisfied about the person’s capacity to
make medical treatment decisions.
As the person’s medical practitioner, the information you provide is vital. It helps VCAT determine
whether a decision reflects the person’s preferences and values or promotes their wellbeing.
As their medical practitioner, you must consider the appropriate time and setting for assessing
accurately your patient’s decision-making capacity.
To appoint a guardian, administrator or make an order about an enduring power
of attorney
Before making an order about a person, VCAT must be satisfied:
•
the person has a disability (neurological impairment, intellectual impairment, mental
disorder, brain injury, physical disability or dementia)
•
the person does not have decision-making capacity to make decisions about lifestyle
or financial matters because of their disability
•
there is a need for a guardian or administrator, usually decided if a less restrictive option
would not meet the person’s needs.
Your medical report will ensure VCAT is aware of your patient’s decision-making capacity about their
personal and financial matters and we promote the persons personal and social wellbeing.
2
PATIENT DETAILS
1. Enter the details of the patient you are completing a medical report about.
Patient name
Date of birth (DD/MM/YYYY)
Address
VCAT reference number (if known) G
BACKGROUND INFORMATION
2. In what capacity do you know the patient?
General practitioner Specialist
Other, please specify:
3. Are you the patient’s regular medical practitioner?
Yes, skip to Question 5 No
4. Provide contact details of the person’s regular medical practitioner (if known):
5. How long have you been the patient’s medical practitioner?
6. When did you last see the patient?
7. Is the patient usually accompanied by someone else when you see them?
Yes No, skip to Question 8
If yes, provide details:
MEDICAL TREATMENT DECISIONS MADE BY THE PATIENT
Complete this section only if this medical report is for a VCAT application to give advice or make
orders about medical treatment. If you are unsure about the type of application your medical report is
for, ask the person who gave you this form.
8. Do you know if the patient made an advance care directive?
Yes No Don’t know
9. If the patient has made an advance care directive, were you involved in the process?
Yes No Don’t know
Page 3
10. Do you consider the patient now has decision-making capacity to make an advance care
directive?
Yes No
Don’t know
11. If you are aware of an advance care directive, do you know the date it was made?
Yes No
Don’t know
If yes, provide the date (DD/MM/YYYY):
12. Did you know this person on the date the advance care directive was made?
Yes No
13. Do you know if the patient appointed a medical treatment decision maker or support
person?
Yes No
Don’t know
14. If the patient has appointed a medical treatment decision maker or support person, were
you involved in the process?
Yes No
Don’t know
15. Do you consider the patient now has decision-making capacity to appoint a medical
treatment decision maker or support person?
Yes No
Don’t know
16. If you are aware of the appointment of a medical treatment decision maker or support
person, do you know the date the appointment was made?
Yes No
Don’t know
If yes, provide the date (DD/MM/YYYY):
17. Did you know this person on the date they appointed a medical treatment decision maker
or support person?
Yes No
18. Do you consider the patient to have decision-making capacity about their medical
treatment?
Yes No, skip to next section Don’t know, skip to next section
19. Does the patient have decision-making capacity to make all or some medical treatment
decisions?
Full decision-making capacity
Some decision-making capacity
20. If you stated the patient has only some decision-making capacity (in Question 19), explain
the types of decisions about medical treatment they are unable to make on their own:
Page 4
DETAILS ABOUT THE PATIENT’S DISABILITY
Complete this section only if this medical report is for a VCAT application to appoint a guardian,
appoint an administrator or about an enduring power of attorney. If you are unsure about the type of
application your medical report is for, ask the person who gave you this form.
21. Does the patient have a disability (neurological impairment, intellectual impairment, mental
disorder, brain injury, physical disability or dementia)?
Yes No
22. Provide details of the diagnosis and history of the patient’s disability:
23. How long has the disability been evident?
years
months
24. What is the current status of the disability?
Static Progressive
Fluctuating
Improving
MEDICAL PRACTITIONER’S OPINION
Complete this section only if this medical report is for a VCAT application to appoint a guardian,
appoint an administrator or about an enduring power of attorney.
The person is considered to have decision-making capacity about a particular matter if they can
make a decision with practicable and appropriate support. Support might include the use of
technology that alleviates the effects of a person’s disability, or someone assisting the person to
communicate their decision.
VCAT wants your opinion as to whether the person has decision-making capacity about the following
matters.
Financial and property affairs
25. Does the patient have decision-making capacity about their financial and property affairs?
Eg. about legal matters, assets and liabilities, expenses and taxes.
Yes, skip to Question 27 No
26. Can the person make decisions about their financial and property affairs if they have
support and they can access that support?
Yes No
Health care
27. Does the patient have decision-making capacity about their health?
Eg. about medical, dental and optical care.
Yes, skip to Question 29 No
Page 5
28. Can the person make decisions about their health care if they have support and they can
access that support?
Yes No
General living circumstances
29. Does the patient have decision-making capacity about their general living circumstances?
Eg. about accommodation.
Yes, skip to Question 31 No
30. Can the person make decisions about their general living circumstances if they have
support and they can access that support?
Yes No
REASONS FOR YOUR OPINION
31. Explain how you formed your opinion about the patient’s decision-making capacity.
Include details and dates of any tests, examinations or assessments.
OTHER FACTORS THAT MAY AFFECT DECISION MAKING
32. In your opinion, are there any other factors that could potentially be impacting on this
patient’s decision-making capacity?
Page 6
33. Do you have any other comments about the patient’s prognosis?
ENDURING POWER OF ATTORNEY
Complete this section only if this medical report is for a VCAT application about an enduring power of
attorney.
34. Do you know if the patient has given an enduring power of attorney?
Yes No, skip to Question 36
Don’t know, skip to Question 36
35. If the patient has given an enduring power of attorney, were you involved in the process?
Yes No Don’t know
36. Do you consider this patient now has the capacity to give an enduring power of attorney?
Yes No Don’t know
37. If you are aware of an existing enduring power of attorney, do you know the date on which
this power was executed?
Yes No, skip to Question 39 Don’t know, skip to Question 39
If yes, provide the date (DD/MM/YYYY):
38. Did you know this person on the date this power was executed?
Yes No
39. Give your opinion on the person’s ability to understand the impact of making an enduring
power of attorney at that time.
Refer to section ‘How we assess if a person is capable of giving an enduring power of attorney’
on page 2.
FURTHER COMMENTS ABOUT YOUR ASSESSMENT
40. Do you have any other observations or comments that may be relevant?
Page 7
ATTENDANCE AT THE HEARING
41. In your opinion, would the patient’s condition prevent them from attending the VCAT
hearing?
Yes No Don’t know
If yes, state your reasons for this opinion:
42. Does the patient require an interpreter?
Yes No Don’t know
If yes, for what language:
43. Does the patient have difficulty communicating?
Yes No Don’t know
If yes, explain:
DETAILS OF MEDICAL PRACTITIONER
44. Enter your details below.
Title
Prof Dr Mr Ms Mx
Name
Qualifications
Provider number:
Street address
Suburb State Postcode
Provide a contact number in case a VCAT representative needs to contact you during the
patient’s VCAT hearing for further information.
Contact number
45. Would you like to receive a Notice of Hearing about this matter?
Yes No
Page 8
ACKNOWLEDGMENT
By completing this application, I understand and acknowledge that:
to the best of my knowledge, all information provided in this application is true and correct
it is an offence under section 136 of the Victorian Civil and Administrative Tribunal Act 1998
to knowingly give false or misleading information to VCAT
Full name of person completing this report:
Date:
SUBMITTING THIS REPORT
Thank you for your time in completing this document, VCAT appreciates this community service.
Please submit this completed report to VCAT either by email or by post.
By email
Email humanrights@vcat.vic.gov.au
By post
Send this report to:
The Registrar
Guardianship List
Victorian Civil and Administrative Tribunal
GPO Box 13193 Law Courts VIC 8010
Page 9
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Completed 8 November 2020

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