The Mental Status Examination or MSE is an important aspect of clinical assessment in psychiatric practice. An MSE is the psychological equivalent of a physical exam and describes the mental state and behavior of an individual undergoing the exam. A Mental Status Examination includes objective observations from the clinician and subjective descriptions coming from the patient.

A clinician who conducts a Mental Status Examination utilizes an Examination Form to create structured evaluation of patients. Experts will then assesses the individual’s psychological functioning based on appearance, attitude, behavior, affect and mood, speech, thought process, thought content, perception, cognition, insight, and judgement.

Mental Status Examination Rapid Record Form

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Mental Status Exam Sample Form

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Short Mental Status Exam Form

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Blank Mental Status Exam Form

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The Purpose of a Mental Status Exam

A Mental Status Examination can be conducted for a lot of reasons, but it is mainly done to provide information that is critical for the diagnosis, the assessment, and the treatment of a disorder.

The Components of a Mental Status Exam

Appearance

Initially, a clinician tries to gauge a patient’s mental state through appearance. A patient’s physical appearance, grooming, the way he is dressed, and his posture are all key components of a person’s mental state based on physical aspects.

Behavior

The next component of a Mental Status Exam is observing the patient’s behavior. Does he make eye contact? Does he fidget or wring his hands? Do you notice any tremors or abnormal movements?

Speech

Assessing a patient’s speech skills gives more focus on the patient’s ability to produce speech rather than assessing the content of the speech. In order to provide a structured assessment of speech, the clinician will ask patients to name objects or repeat short sentences. By observing a patient’s way of speaking clinicians will be able to observe para-linguistic features like loudness, rhythm, intonation, pitch, articulation, rate, spontaneity, and latency of speech.

Assessing a patient’s language skills will make possible the recognition of medical conditions such as dysathria, neurological conditions like stroke or dementia, and specific language disorders like stuttering or mutism.

Mood and Affect

Mood is a patient’s dominant emotional state which he tells you he feels. Descriptions of a patient’s mood are sometimes indicated with the use of quotation marks to show that those were the patient’s exact description, for example, “Angry, sad, and frustrated.”

A patient’s affect, on the other hand, is the emotional state that clinicians observe such as euthymic if the patient is in a normal mood, dysphoric if the patient looks depressed or angry, euphoric if the patient is elevated.

Related Links: Health Examination Forms

Mental Status Exam Form for Child

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Mental Status Exam Form in PDF

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Mental Health Status Exam Form

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Psychiatric Mental Status Exam Form

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Thought Process

Another aspect of a Mental Status Exam is to observe if the patient has the ability to process information correctly. How a patient perceives and responds to stimuli is important in a pychiatric assessment because the inability to do so may be a sign of psychosis.

When assessing a patient’s ability to process information, a clinician observes if the patient harbors realistic concerns or if the patient is responding to actual events in an exaggerated way.

Thought Content

Thought Content covers observations on a patient’s thoughts, such as delusions, overvalued ideas, phobias, hallucinations, and obsessions.

Abnormalities of the Thought Content aspect can be determined by exploring an individual’s thoughts through open-ended conversations.

Cognition

Cognition determines a patient’s level of alertness, orientation, attention span, memory, language, and executive functions. Does the patient have the ability to focus, sustain, and properly shift his mental attention?

Insight or Judgment

Insight is a patient’s understanding of the problem and the options of treatment. Judgement, on the other hand, pertains to the patient’s capacity to make sound, responsible, and reasonable decisions.

Related Link: Dental Examination Forms

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