Mental Status Exams: 10 Best Templates, Questions & Examples

There are various ways to gather such information, from brief check-ins to more extended or formal evaluations.

Most formal examinations involve questioning clients in depth about their functioning and systematically noting how they behave.

One of the most common types of formal evaluation in psychiatry, psychology, and related fields is the mental status examination (MSE).

The MSE can provide future report readers with a valuable window into how a client presented at a given time, including negative and positive signs.

In this article, we describe the standard components of the MSE and provide tips on how best to conduct it. We also offer several templates, a checklist, and questions that can be added when completing an MSE.

These science-based exercises explore fundamental aspects of positive psychology, including strengths, values, and self-compassion, and will give you the tools to enhance the well-being? of your clients, students, or employees.

What Is the Mental Status Examination (MSE)?

The MSE is a method used to document an individual’s basic cognitive, emotional, and behavioral functioning at a given time (Martin, 1990).

This method has traditionally been used in psychiatry and clinical? psychology but has also been adapted for other helping professions like social work and coaching.

The method usually includes a structured interview and systematic behavioral observations.

There is significant variability among the forms used by different practitioners to gather this information from a client.

At the same time, core domains should arguably be covered whenever an MSE is done.

The Domains Included in the MSE: 14 Examples

Standard fields covered in the MSE include:

• Level of consciousness
  This refers to the client’s alertness and responsiveness to questions or other stimuli.
• Orientation
  Awareness of date/time, current location, and current situation (e.g., the reason for an appointment).
• Gross/fine motor movement
  The client’s gait, posture, manual dexterity, etc.
• Dress/grooming and hygiene
  Is the client neatly dressed or more disheveled? Neatly or poorly groomed? Are they attending to personal hygiene?

Note: these do not value judgments but descriptors that reflect a client’s functioning or insight. If their clothes are dirty and they are poorly groomed or unshaven, this tells the examiner something about their typical level of self-care and areas in which they might need help.

• Sensory function
  Can the client hear enough to understand questions and see well enough to complete forms or visual tests?
• Speech
  A client’s speech pattern is typically described in terms of fluency (the ease or flow), rate (from slow to rapid to pressured), volume (from soft to loud), and intonation (from regular to flat or monotone, as well as any odd tonality, such as in foreign accent syndrome? (Kurowski, Blumstein, & Alexander, 1996).

Speech is a binding domain, as it carries much verbal and nonverbal information, including about emotional state and coherence of thought.

• Affect
  A client’s range of emotional expression is based on their speech, facial expressions, or other behaviors.
• Mood
  What the client reports about their internal mood state, especially as concerns any depressive or anxious symptoms.
• Attention/working memory
  Ability to focus on tasks (attention) and briefly hold information in mind (working memory) before using it. This domain is based on examiner observations, client self-report, or brief tests such as counting backward from 100 by 7s.
• Memory
  Ability to recall information based on examiner observations, client self-report, or brief tests, such as short-term recall of three objects stated to them.

Note: Cognitive assessment? within an MSE, covering essential attention and memory capacities, is typically done by psychologists, neuropsychologists, or psychiatrists with specialized training in this area.

• Thought process
  The flow and coherence of thoughts are inferred from a client’s observable behaviors, especially speech. For example, if the client’s address is rambling and disorganized, the examiner may assume that their thinking is illogical.
• Thought content
  Thought content can be inferred from the examiner’s spontaneous speech and direct questioning. For example, the examiner might ask, “Have you ever heard things others don’t hear or seen things others don’t see?” A ” yes ” answer to such questions raises the possibility of hallucinatory thought content.
• Insight
  How aware is the client of their strengths and limitations?
• Strengths and limitations
  Traditional forms of the MSE have been designed to record any cognitive, emotional, or behavioral deficits.

There is nonetheless room for developing questions and behavioral observations to explore and document the client’s strengths in the MSE.

Pros and Cons of the MSE

A structured MSE with a user-friendly examiner form helps ensure that all crucial dimensions of a client’s presentation are explored without neglecting any.

For example, mood is a binding domain to assess when examining a client. It is a domain to be queried in almost all MSE measures.

On the other hand, there are numerous forms of the MSE and no universally accepted format, which can cause some confusion? among practitioners.

Below, we offer three MSE sample templates. We also include sample write-ups for the MSE and a comprehensive MSE checklist.

Useful Templates, Samples, and a Checklist

As promised, you will find helpful mental status examination templates, samples, and a checklist below.

3 MSE templates

Here are three mental status examination templates. These templates include a brief MSE format and two more comprehensive and detailed formats.

1. Brief Mental Status Exam Form
2. Mental Status Examination/Behavioral Observations
3. Mental Status Exam and Behavioral Observations

Sample MSE write-ups

The first of these samples use brief comments that efficiently convey all needed information. The second sample is in a longer prose style. Either style can share crucial information about a client’s cognitive, emotional, and behavioral status.

1. Child/Adolescent sample*

Behavioral observations & mental status:

• Alertness: Alert
• Orientation: Fully oriented
• Appearance: Congruent with age, well groomed, and appropriate dress
• Demeanor: Easy to engage, polite, cooperative, and good eye contact
• Attention: Adequate to engage in conversation, although mild? distractibility was noted on testing
• Language: Fluent and without word-finding difficulty
• Memory: Intact autobiographical memory
• Motor: No motor abnormalities were observed
• Empathy: Intact
• Mood: Normal
• Affect: Full and reactive
• Thought process: Linear, logical, and goal-oriented
• Thought content: Appropriate, with no psychosis, hallucinations, or suicidal or homicidal ideation
• Impulsivity: Mild
• Judgment: Good
• Insight: Good

*Sample provided by Sarah Bullard, Ph.D., ABPP, used with permission

2. Adult sample

This 65-year-old woman came alone to testing, having driven herself. She appeared her stated age. She was mildly disheveled in dress and indifferently groomed. Her gait appeared mildly unsteady, and she walked with a cane (“I fell down in my house recently, so now I walk with a cane.”).

She was oriented to place and situation but less well to time (missing the day of the week by one, and at first unsure of the year). Both hands had a mild tremor?, which increased when reaching for objects with the right hand.

The vision appeared adequate for reading forms, but hearing seemed mildly impaired, with the client needing some information repeated. The speech was halting in fluency, with evident word-finding difficulty; mildly loud; with flat intonation.

Affect was generally flat but with some lability (periodic crying spells when discussing current loneliness). She described her mood as “down” most days. She said when she felt down, it was usually because “I’m always alone now, since my husband died three years ago.”

She denied any thoughts or tendencies toward self-harm. She reported some memory difficulties, especially with new information. When questioned about alcohol intake (a concern included in physician referral), she said she drank “a few – three or four – glasses of wine” every night but did not consider this a problem.

Insight appeared limited in this latter respect. The social judgment seemed to be intact, based on questioning about a hypothetical scenario (“What would you do if you found a wallet on the floor in a supermarket?” “Bring it to customer service.”).

There was no evidence of formal thought disorder or abnormal thought content. Motivation/effort on testing was variable (gave up quickly as test items became moderately tricky).

Checklists

Some examiners prefer the convenience of a checklist when conducting an MSE, which they can later expand upon in drafting a formal report.

Descriptors and Terminology to Use

The following worksheet lists common terminology and descriptors that can help make MSE write-ups intelligible to subsequent readers of reports. Shared vocabulary would prudently include the following, with associated descriptors (generally on a continuum from normal to abnormal):

7 Questions to Ask Clients

The MSE questions below can be modified to fit the clients you typically work with.

1. What benefit do you hope to gain from this (psychiatric, psychotherapeutic, social work, coaching, etc.) service?
2. What are your strong points? What are you particularly good at? (See strengths exploration form below.)
3. Do you have any psychological, social-emotional, academic, or vocational difficulties you would like help with?
4. Have you had any psychological or other interventions in the past, such as psychotherapy, job coaching, etc.?
5. What, if anything, has worked for you in the past as an intervention?
6. What are your primary goals in life? (See the goal-setting form below.)
7. What are the obstacles, if any, to reaching your goals?

Helpful Videos and Books on This Topic

To learn more about MSE, we share a YouTube video and two books to enhance your understanding of the process.

Mental Status Examination With John Sommers-Flanagan

This video is one example of how an MSE might be conducted. The examiner here is an experienced clinician skilled at working with individuals in a psychiatric context who might need gentle redirection back to the topic at hand (Sommers-Flanagan, 2020).

The following mental health books are also recommended.

1. Mental Status Examination: 52 Challenging Cases, DSM and ICD-10 Interviews, Questionnaires and Cognitive Tests for Diagnosis? and Treatment – Wes Burgess

This book details how the mental status examination is typically done and provides numerous vignettes of various client types and how their strengths/limitations can be assessed.

Readers rate it as highly engaging and valuable for many practitioners in the helping professions.

Find the book on Amazon.

2. The Mental Status Exam Explained – David J. Robinson

Readers have rated this book as highly accessible and practical in terms of learning to do mental status examinations.

The MSE is as crucial to psychiatry as the physical exam is to other areas of medicine. This text provided a practical, concise, and enjoyable introduction to the MSE.

Find the book on Amazon.

A Note on Using the MSE With Children

The following points about conducting MSEs with children are adapted from Martha J. Faulkner’s Pediatric Mental Status Exam.

• Be welcoming to the child.
• Allow the parent in the room if this helps soothe the child. If separating from an adult for a time is needed, note if this is easy or difficult for the child.
• Acknowledge and, where possible, validate the child’s concerns.
• Encourage the child to explain things on their terms.
• Does the child appear well nourished and physically well developed?
• Emphasize open-ended questions.
• Be empathic.
• Observe the child’s manner of relating to others. Does the child appear immature or intelligent for their age?
• Carefully distinguish between such phenomena as fanciful ideas, imaginary friends, or inner voices (familiar in childhood) versus delusions or visual or auditory hallucinations (not common in childhood).

A Take-Home Message

The mental status exam is a critical component of evaluations across the helping professions.

When correctly done, an MSE and its accompanying write-up provide a valuable window into a client’s functioning at a given time.

It also serves as a helpful point of comparison with a client’s documented functioning at other times.

Conducting an MSE requires behavioral observation skills, experience in interviewing, and flexibility in adapting questions to a client.

There should be flexibility in asking questions that might be off-template, as this can help capture a client’s unique profile related to their strengths and limitations.

By following a comprehensive template while interviewing clients and observing their behavior, you can be confident you have not missed crucial information about their status.

We hope you will find this article’s various MSE templates, checklists, and domain descriptors useful in your work with clients.