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What to Include on a Mental Status Exam [Editable PDF Template]

As a practitioner, a mental status exam is a must for each patient you see. In this post, we are going to dissect the different components of a mental status exam as well as show you an example of a mental status exam. Finally, you can download our editable PDF that can be used digitally for each of your patients.

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What is a Mental Status Exam?

A mental status examination is an important part of the clinical assessment process in a neurological and/or psychiatric practice. According to Merck Manuals, The mental status exam is an “assessment of current mental capacity through evaluation of general appearance, behavior, any unusual or bizarre beliefs and perceptions, mood, and all aspects of cognitive function.”

According to the Washington State Department of Social and Health Services, A mental status exam must include detailed observations regarding your patient’s appearance, speech, attitude, behavior, mood, and affect. If not within normal limits, the mental status exam must also include detailed observations regarding your patient’s thought process and content, orientation, perception, memory, fund of knowledge, concentration, abstract thought, insight, and judgement.

Why is a Mental Status Exam Helpful to Mental Health Professionals?

A mental status exam is a useful tool to assist mental health professionals in differentiating between different systemic conditions, as well as neurologic and psychiatric disorders.

When evaluating a patient, mental health professionals must take into factors that can affect performance such as:

  • Level of education
  • Culture
  • Native Language
  • Social factors
  • Literacy
  • Hunger
  • Other Stressors

A mental status exam is structured in a way that allows a practitioner to observe and describe a patient’s psychological functioning at any given point in time. It is a key tool in outpatient and psychiatric hospital settings to obtain evidence of symptoms and signs of mental disorders present at a given time. In addition, a mental status exam can provide evidence needed to make proper treatment decisions and an appropriate treatment setting for your patient. In summary, a MSE is an essential tool needed to properly assess clients and patients.



Mental Status Exam Components to Include

Appearance

Here are some examples of appearance observational questions you can answer about your patient:

  1. Is my patient well groomed or unkempt?
  2. What is my patient wearing?
  3. Are my patient’s clothes appropriate for the weather and the situation they are in?

Speech

Here is an example of a speech observational question you can answer about your patient:

  1. Is my patient’s speech normal, pressured, tangential, or circumstantial?

Attitude and Behavior

Here is an example of an Attitude and Behavior observational question you can answer about your patient:

  1. Is my patient calm, cooperative, uncooperative, or belligerent?

Mental Status Exam Mood

Mood

Here is an example of a mood observational question you can answer about your patient:

  1. Is my patient’s mood euthymic, irritable, elevated, anxious, or depressed?

Affect

Here is an example of an affect observational question  you can answer about your patient:

  1. Is my patient’s affect within a normal range, are they depressed, constricted, flat, labile, blunted, reactive and mood congruent, or tearful?

Thought Process and Content

Here are some examples of thought process and content observational questions you can answer about your patient:

  1. Is my patient logical or disorganized?
  2. Does my patient have any delusions, phobias, or obsessions/compulsions?
  3. Is my patient suicidal and/or homicidal?

Orientation

Here is an example of an orientation observational question  you can answer about your patient:

  1. Is my patient oriented to time and place?

Perception

Here is an example of a perception observational question  you can answer about your patient:

  1. Did my patient display signs of hallucinations or delusions during my interview?

Memory

Here are some examples of memory observational questions you can answer about your patient:

  1. Can my patient remember past events? (remote)
  2. Can my patient remember 3 of 3 objects after 5 minutes? (recent)
  3. Can my patient perform digit span? (immediate)

Fund of Knowledge

Here are some examples of fund of knowledge observational questions you can answer about your patient:

  1. Is my patient aware of current events? Make sure to include examples.
  2. Does my patient know the names of the president or other important political figure?
  3. Can my patient answer simple geography questions, like what are the largest cities in his/her state?

Concentration

Here are some examples of concentration observational questions you can answer about your patient:

  1. Can my patient spell TOOTH forward and backwards?
  2. Can my patient count down by 7 or 3 from 100?
  3. Can my patient follow a 3 step command?

Abstract Thought

Here is an example of an abstract thought observational question  you can answer about your patient:

  1. Can my patient interpret proverbs?

Insight and Judgement

Here are some examples of insight and judgement observational questions you can answer about your patient:

  1. Does my patient have insights into their condition?
  2. Does my patient show good judgement? For example, ask the patient what they would do if they smelled smoke in a crowded arena

Creating a mental health exam


Mental Status Exam Example

If you need to see a mental status exam example, here is the template we’ve built:

In this mental status exam example, you’ll see important categories with a scale of options to grade a patient’s appearance, speech, attitude, behavior, mood, affects as well as detailed observations regarding your patient’s thought process and content, orientation, perception, memory, fund of knowledge, concentration, abstract thought, insight, and judgement.

Creating a Mental Status Exam

When it comes to obtaining a mental status exam, you can either create your own or use a templated option. While creating a custom intake forms may sound like a good idea, it can be costly for your private practice. Our template allows you to fill out the form on your computer and store it electronically. This can be invaluable to organizing documents by patient in your practice. You can also use our PDF to upload to HIPAA compliant docusharing companies that can help you obtain signatures online.

Download our editable mental status exam pdf template:

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Download Our Mental Status Exam PDF Template

DOWNLOAD NOW

Final Thoughts on Your Mental Status Exam

Thank you for reading our blog on what to include on your mental status exam, we hope it was of incredible value to your practice. Your mental status exam is crucial to properly assessing your patients, and a digital copy of your mental status exam is valuable to the health of your private practice. Being able to efficiently fill out and digitally store your patients’ mental status exam securely will help your private practice operate in a way that will set you up for many years of success.

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Anthony Bart
Author: Anthony Bart

Anthony Bart is a huge mental health advocate. He has primarily positioned his marketing expertise to work with mental health professionals so that they can help as many patients as possible. He is currently the owner of BartX, TherapistX, and TherapyByPro.

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