Writing a Mental Status Exam

A few months ago I received a question about writing mental status exams (MSE) and realized I've never talked about this! So, here is some direction regarding all things MSE...

What is a Mental Status Exam (MSE)?

A mental status exam is a brief snapshot of a client's presentation. The MSE is meant to assist with diagnosis, capturing and identifying symptoms, but also to create a succinct picture of the presentation at a specific moment in time.

This means that a person's MSE may appear very different at various stages in treatment, and that's perfectly fine. For example, a client experiencing a manic episode will present very differently at the height of the episode than they will during times of mood stability or during a depressive episode. 

I should note that an MSE is always meant to be completed by the clinician who saw the client, and should include a visual assessment (meaning over the phone would not capture many of the applicable sections). 

The MSE is generally more useful for clients with acute, chronic or more severe symptoms. While it can be useful in all circumstances, many sections may not apply to clients with general adjustment or change of life issues. 

When to Use a Mental Status Exam

The most common use for the MSE is during a clinical assessment. The MSE can actually provide a great source of documentation to support diagnoses for clients. If you have difficulty diagnosing or worry about substantiating diagnoses for insurance companies, try using a mental status exam and then make sure DSM diagnostic criteria match up with the identified presentation. 

An MSE is generally completed during the first 1-2 sessions, and then any other time when re-assessing symptoms. 

That might include regular intervals of time, in order to identify progress, or only as needed during the treatment process. It can be helpful to complete one at the end of treatment to highlight any differences in presentation and celebrate growth.

Some clinicians do complete a brief MSE as part of every progress note but I find this unnecessary in most cases. Of course, that is a preference and if using the MSE every time works for you, great! Just remember to include some information about what transpired during the session, as well. 

How to Complete a Mental Status Exam

Like it or not, mental status exams were created to capture dysfunction, not ordinary function. That's why you'll find most of the categories very "clinical" sounding.

For this reason, it is generally acceptable to simply mark "Within Normal Limits" (or "WNL" for short) if there is no impairment found in the identified section. However, this creates that sense of obligation without purpose in documentation that you know I dislike! 

That's why I recommend that if you are using an MSE, then describe each section regardless of the impairment.

And if you don't find this useful, don't do an MSE! Or, perhaps pare down your MSE so that it only includes the sections you find helpful. These don't have to be long descriptions. Remember, the MSE is meant to be a brief assessment, a snapshot. Keep your answers to just one or two sentences, at most. 

Recommended Mental Status Exam Sections

I am listing these alphabetically, in order to keep things simple. However, these are often listed in notes more by level of depth or order of importance. Many sections are often combined so I have either outlined this or included the common names together.

Affect

Different from and similar to mood (below), affect is a bit more descriptive regarding how a client is presenting their mood. For example, affect and mood may both be depressed or sad. The client describes themselves as sad and appears to be so. 

However, affect can also include things like constriction, range of emotion, and appropriate expression of emotion. For example, mood was depressed and affect blunted. In this example, affect is describing the fact that the client exhibited limited emotion, although they may actually be feeling quite depressed. 

Due to the similarities and how these interact, affect and mood are often combined into one section on an MSE "Affect/Mood." I only included them separately here to review the difference between them. 

Appearance

Self-explanatory, this is literally the physical appearance of the client. Note any unusual physical characteristics, grooming and clothing.

Tip: Stay objective here and avoid phrases like "attractive" that can be offensive and subjective depending on the person describing attractiveness. 

Behavior

This is the physical behavior present during your assessment. Here you will note how the client moved and acted physically. This could be something like frequently fidgeting, shaking leg, unable to sit still, or walked very slowly. It may also include things like yelling or crying. 

Concentration

Here you will note any difficulties with concentration, such as difficulty tracking the conversation, frequently getting distracted or going off task.

Insight/Judgement 

A more subjective measure, in this section you will comment on your perception of the client's insight based on the interview. You may note things like how well your client understands the reasons for their behavior or contribution to a problem, whether or not they recognize the severity of a problem, and what is their perception of how to address problems. 

Intelligence/Cognition

Here you can describe the client's abilities based on the information you've gathered so far. In general, this is really meant to capture the more extreme ends of the spectrum, such as significant cognitive deficits or very advanced vocabulary for developmental age. 

Some clinicians will actually test things like working memory briefly during an MSE by doing serials 7's (counting backwards from 100 by 7's), having a client spell "world" backwards. While impairments here may alert you to something, they are certainly not an indicator of actual intelligence.

Memory

You may do a brief test of your client's memory (asking them to remember something at the beginning and then at the end) but then you again have a very low validity picture of memory. It is best to use this section to comment anecdotally on what was noticed during the session. Did your client leave out important details frequently? Have trouble remembering important events or specific periods of time? Also note if they identify any concern about their memory. 

Mood

This one seems obvious and yes, it sort of is. Mood includes common descriptors of how people are feeling and may use traditionally clinical language or more commonly used laymen's terms. These include phrases like depressed, anxious, worried, sad, euphoric, happy, irritable, etc.

Orientation

This is probably the category most commonly used in the medical field and always included in general mental status exams. Orientation refers to how well the client was oriented to person (themselves), place (the setting in which your assessment occurred, as well as their general location), time (date, time of day) and situation (physical and emotional situation). Note that situation is usually but not always included.

This is typically a very brief section, simply noting something like "Client was oriented x4" or "Client was oriented to person but not time, situation or place."

Perceptual Disturbance

This section has some crossover with thought process and content but could be used to highlight things like hallucinations, if that is a common symptom you see. If so, identify the type of hallucination (e.g. auditory, visual, etc.) and any relevant info.

Speech

Another self-explanatory category, here you will consider anything related to speech quality. This includes things like speech impediments, rate of speech, volume, etc. 

Strengths

This category is not always included in common MSE templates, but I always work from a strengths-based and client-focused perspective, so I'm including it here. You can identify strengths you noticed during your meeting with the client, and also ask the client (or parent/guardian) to identify strengths.

Suicidality/Homicidality

Here you will acknowledge your assessment of these areas and specifically note whether or not the client denied these, has a plan, has ideation only, etc. 

Even if your client was noted to be suicidal with a plan, don't feel the need to include extra information here. That will all be in your progress note where you describe your assessment in more detail, along with the identified plan. 

Thought Content

This section captures what was the main content your client presented during your session, as well as any noteworthy content items that came up. This may include delusions and hallucinations, if you prefer not to have a separate category for these symptoms. 

Regardless of things like delusions, this is also the area to include things the client focused on as important. That may be feelings of guilt, preoccupation with a particular topic (video games, sex, a specific person, etc.), irrational worries or even phrases that were repeated throughout. 

Thought Process

While content focuses on what was discussed/presented, process focuses on how the client presented that information. This includes things like ability to think abstractly, connections made as explanation for behaviors or mood, associations and ability to stay on track, flight of ideas, or magical thinking. 

Yes, there may be some crossover here with things like concentration and insight/judgement but this section really pulls those pieces together to describe how the client views the world and themselves.

Create Your Own Mental Status Exam

If you're in private practice then you have the flexibility to use which sections you like, complete an MSE whenever you feel it is relevant, or even avoid it altogether

I recommend you look through the sections and then identify anything you think would be helpful to document during intake assessments, then anything that may be helpful to track over time at various intervals, and anything you'd like to capture at the end of treatment for a more objective view of progress. 

You may find certain sections more or less relevant for different clients, and that's okay. Think about your current clients. If a section applies to at least half of them, then it will likely prove useful to you. If not, then scratch it and just add that in when it's needed.

You can also create an "Other" category for random things that come up but don't fit anywhere else. Simply use that as your catch all and then take note if you find yourself including the same thing over multiple clients. Then maybe it should become it's own category.

You have the power here to make the mental status exam whatever you'd like it to be for your practice. So make it meaningful to you and helpful to your clients. Otherwise, there's no point!

Let us know in the comments below... do you use a mental status exam in your practice?

What tips have you found to make it meaningful and easy to complete?