Mental Status Exam Template

The mental status examination is a structured assessment of the patients behavioral and cognitive functioning.

Mental status exam template. Mental status exam form client date ethnicity apparent age younger stated age older handedness right left sex male female build. If there is any indication of current suicidal or homicidal ideation in the child or adolescent they must be referred for further assessment by a mental health clinician. 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. In following pages there are elaborations of each section with sample descriptors.

A synopsis of the four mse sections is presented below. Behavior no unusual movements or psych omotor changes other describe. The mental status examination or mse is an important aspect of clinical assessment in psychiatric practice. The state what is the capitol of the state what direction does the sun set.

3uhsduhg e 5lfkdug dnhpdq 8sgdwhg zzz whvwdqgfdof frp 7krxjkw rup odulw rkhuhqw lqfrkhuhqw forxg frqixvhg ydjxh 5hohydqfh orjlf rjlfdo loorjlfdo uhohydqw ru luuhohydqw wr wrslf ehlqj glvfxvvhg orz flwhg ioljkw ri lghdv wdqjhqwldolw sryhuw ri wkrxjkw zrug. These sample reports can be helpful if youre learning to conduct mental status examinations and write mse reports. An mse is the psychological equivalent of a physical exam and describes the mental state and behavior of an individual undergoing the exam. The mental status exam mse is the psychological equivalent of a physical exam that describes the mental state and behaviors of the person being seen.

It includes descriptions of the patients appearance and general behavior level of consciousness and attentiveness motor and speech activity mood and affect thought and perception attitude and insight the reaction evoked in the examiner and finally higher cognitive abilities. Speech normal ratetonevolume wout pressure other describe. The mental status exam mse is a standard tool used by clinicians to assess the basic functioning of a client. Appearance casual dress normal grooming and hygiene other describe.

Affect reactive and mood congruent labile. Interpretation of the mse must keep in mind the patients age and developmental level. This is a photo of me checking my mental status. The assessment categories include mood cognition perception thoughts behaviors insight and judgement.

A mental state examination mse is a part of every mental health assessment. Mental status exam heidi combs md what it is it. An mse is often completed during an initial psychosocial and at regular intervals throughout treatment. Why do we do them.

Sample proverbs a rolling stone gathers no moss in the land of the blind the one eyed person is king. It includes both objective observations of the clinician and subjective descriptions given by the patient. Attitude calm and cooperative other describe.