Mental Status Exam Template

The mental status exam mse is a standard tool used by clinicians to assess the basic functioning of a client.

Mental status exam template. Brief mental status exam mse form 1. Mental status exam items american physician institute for advanced professional studies llc 877 225 8384 general appearance alertness. Appearance casual dress normal grooming and hygiene other describe. As stated younger older race ethnicity.

Affect reactive and mood congruent labile. Attitude calm and cooperative other describe. Reveals a small but well nourished well developed female who looks slightly younger than her stated age. The mental status exam is a snapshot of a patient that describes their behaviours and thoughts at the time you interviewed them.

The assessment categories include mood cognition perception thoughts behaviors insight and judgement. She is alert attentive accessible to examination. Hygiene and grooming are satisfactory. A synopsis of the four mse sections is presented below.

The data from the mental status exam combined with personal and family histories and psychiatric review of systems forms the data base from which psychiatric diagnoses are formed. An mse is often completed during an initial psychosocial and at regular intervals throughout treatment. An mse is the psychological equivalent of a physical exam and describes the mental state and behavior of an individual undergoing the exam. Her speech is rapid garbled and difficult to understand.

Normal decreased increased distractibility. Think about how a psychotic individual s mse might change over the course of a few hours or how a manic patient might similarly fluctuate. Normal decreased increased arousa. In following pages there are elaborations of each section with sample descriptors.

Behavior no unusual movements or psych omotor changes other describe. Speech normal rate tone volume w out pressure other describe. Mental status exam form client date ethnicity apparent age younger stated age older handedness right left sex male female build average underweight healthy thin petite stocky stature below. Sample proverbs a rolling stone gathers no moss in the land of the blind the one eyed person is king.