Just like stepping into a foreign country where tones, gestures and even non-verbal cues are different, so mental health practitioners need to pay attention to the mannerisms, behaviors and speech patterns of their patients. Mental status exam templates give a format to interpret all those details.
Mental status exam templates enable therapists and clinicians to organize and communicate their observations in a succinct manner. As such, practitioners can make informed decisions on the best diagnosis and treatment.
In this article, we’ll review the most relevant mental status exam templates. We’ll also include tips for gathering the mental status exam (MSE) information, including examples of questions to get the most objective data.
While the MSE is essentially a physical exam for psychiatry and should be done in person, there are many ways that digital tools can support you as a practitioner.
For example, Quenza is both a client and practitioner platform so you can decide what to share with your clients. Everything is then stored safely, according to HIPAA and GDPR privacy regulations.
Based on the MSE, you can then create the perfect client journey to work towards improving their mental status and overall well-being. Each of the many activities in the Quenza library can be combined in unique pathways to offer an interactive and customized experience.
See for yourself by signing up for the free, full-access, one-month $1-only trial just how many creative ready-made activities you have access to. You’ll transform your clients’ journeys into experiential moments where they feel empowered.
The Purpose of the Mental Status Exam
The mind naturally focuses on symptoms. It takes discipline and training to hold off judgment to work through a systematic root cause analysis process. The MSE is part of that process.
So, what is a mental status exam? It’s a framework to guide clinicians when gathering information about their clients. They can then use this information to evaluate potential mental health disorders and so make their psychiatric diagnosis.
More specifically, using mental status exam templates allows mental health practitioners to highlight between mood disorders, thought disorders or cognitive impairment. They are then in a better position to advise on the best course of treatment or to refer the patient [1].
The MSE originates from the field of psychiatry, neurology and clinical psychology but it can be adapted by anyone working in mental health. Coaches and social workers can also use mental status exam templates to help them evaluate the root cause of their clients’ issues.
Habits and behaviors are often deeply ingrained and influenced by culture, society, gender, among other factors. While a coach might not ask questions to determine mental orientation, they could seek to elicit insight, cognitive awareness, thought process and perception. These factors of the MSE are valuable pieces of information for holistic coaching.
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Carrying Out A Mental Status Exam
As the MSE is not standardized, there are various mental status exam templates a practitioner could use. As a result, there’s no set answer to the question “how long does a mental status exam take’. Although, generally, it can be completed in one session of anywhere between 45 and 90 minutes, depending on the patient.
While mental status exam templates all differ slightly, there are common sections covered as detailed below [2]:
• Appearance, attitude, activity
• Mood and affect
• Speech and language
• Thought process, thought content, perception
• Cognition
• Insight and judgment
When searching for mental status exam examples, you’ll soon see that each template has different suggestions of checkboxes for each section. The overall aim remains the same though. By objectively gathering all observations, mental health professionals can make better diagnoses with more effective treatment plans.
Where confusion sometimes arises is that as there is no set template, practitioners are not always sure if they’ve covered everything. Moreover, it’s very difficult and virtually impossible to completely remove all our biases.
For example, mood and affect aren’t easy to differentiate. To help practitioners, the Psychiatric Mental Status Examination Guide book defines 6 clusters to describe mood and affect [2]:
• Euthymic e.g. calm, friendly, unremarkable
• Apathetic e.g. bland, flat
• Angry e.g. hostile, frustrated
• Euphoric e.g. cheerful, elated
• Dysphoric e.g. grieving, hopeless
• Apprehensive e.g. nervous, overwhelmed
They then include 5 parameters to gauge affect which is more fleeting and often with constant fluctuations [2]:
• Appropriateness
• Intensity
• Mobility
• Range
• Reactivity
The book obviously goes into more detail and every practitioner can also include their own questions for each section. Then again, you might also want to start with some ready-made mental status exam templates. So, we’ve picked out some top ones to get you started.
Examples of Mental Status Exam Templates
| Overview | |
|---|---|
A brief MSE form with tick boxes to fill out | |
A free-flow form with brief examples for each of the MSE themes | |
A comprehensive booklet of clinical forms, including a more detailed MSE form |
Searching for the Root Cause
As you can see, there are many different mental status exam templates out there. Some of you might even have some left over from your study years. The main point when answering the question “what is a mental status exam” is that it’s part of the puzzle.
This part should be combined with other medical records and referral therapy notes where applicable. Remember that each section can also quickly become a judgment. As such, it’s critical to keep in mind the patient’s background. Where they might see something as normal, might not be normal for someone else.
Overall, mental status exam templates provide discipline because the skill is to avoid judgment. Only once you’ve combined the MSE with other data points can you start hypothesizing about possible diagnoses. Sometimes those might still need to be further tested.
Examples of Questions to Further Test Each of the MSE Themes
| Overview | Potential Questions | |
|---|---|---|
Appearance, attitude, activity | How well-groomed they are and including signs of aging or other distinctive features. Also includes examining the client’s approach to the session and the level and quality of their motor movements. | How do you see therapy benefiting you? What would success look like for you? |
Mood and affect | Relates to the client’s subjective emotional state. The current affective state is also explored through questions or observations of tone of voice, posture, energy levels and other movements. | How have you been feeling recently and now? What mood changes do you experience normally? The wheel of emotion can be a useful tool to refer to. Other behavioral and mood clinical tests can be found online with, for example, Pearson’s Q-Global. |
Speech and language | Observe both the semantic, or ability to convey meaning, and motoric, or the ability to assemble language and non-verbal expressions. Particular care needs to be taken here to ensure that language disorders such as aphasia are not confused with thought disorders. | A general impression is soon made but some more extreme cases will need specific naming, comprehension, writing and reading tests. |
Thought process & control, perception | Observe patterns of ideas and how connected they are without necessarily discounting creativity which can also appear disorganized. | What current issues or blocks are you facing? What is driving you to get help? What type of thoughts do you tend to have? What happens in your mind when you daydream? |
Cognition | Looking for alertness and general responsiveness. Memory is often also tested as well as orientation to time, place, person and situation. | Various cognitive tests, including visual memory tests, can be found online where relevant. Otherwise, a judgment can be made with questions such as “what are your strengths” or “how do you rate your problem-solving/critical thinking skills”. |
Insight and judgment | Testing both self-awareness and critical thinking while balancing various viewpoints. Also relates to how a client sees cause and effect and their locus of control. | What feedback do others give you and how does it apply to you? What do you think is the problem / wrong with you? How does your behavior impact others around you? What drove you to that decision and what lessons did you learn? What coping skills do you tend to turn to? |
Optimizing Mental Status Exam Templates
A review of commonly used “Mental Status Exam templates” will show you that there’s a lot of overlap between them. That being said, as a practitioner, you might want to fine tune and create your own template.
You can even start creating it now with Quenza by signing up for the free, full-access, one-month $1-only trial.
First, you can use the Quenza Pathways Builder to plan the investigation period. The MSE can be part of that as can other forms such as the Hamilton Anxiety Scale or others.
Then, you can record the mental status exam templates as part of your own personal notes attached to each client page. You decide what they can see and access. Either way, don’t forget to use best practice note-taking with SOAPor GIRP, for instance.
At this point, you might be wondering “how long does a mental status exam take”. On the digital side, preparing the templates takes minutes. In person, they can take a whole session or even several sessions. As you build trust and rapport, you’ll be able to go deeper with your clients. This especially applies to the sections on cognition, thought, insight and judgment.
Furthermore, just like you can create your very own therapy forms, you can build your own MSE. The activity builder is straightforward to use and gives you a range of pre-made fields such as:
• Text boxes
• Multiple-choice fields
• Checkboxes
• Drop-down menus
• Custom linear scales, and more.
You can also transform your MSE into surveys, as shown below:
In short, you can make your MSE as digitally and physically interactive as you want. Everything is then stored on Quenza’s compliant platform and the paperwork is done for you.
Case Studies Using The Mental Status Exam
As you can imagine, mental status exam examples differ per client. Some will be angry and withdrawn but others will be confused and apathetic.
To give you more specific examples of using mental status exam templates, here are two hypothetical cases for which you can find more details in The Psychiatric Mental Status Examination book [2]:
1- A middle-aged woman is going through a divorce and has threatened suicide.
• Appearance, attitude, activity – unkempt, eyes downcast, cooperative
• Mood and affect – hopeless, depressed
• Speech and language -monotone with long pauses
• Thought process, thought content, perception – suicidal thoughts but not homicidal and with no hallucinations
• Cognition – orientation level 3 with some confusion around the current situation
• Insight and judgment – unrealistic negativity about the world
The client is suffering from major depression and will most likely need a combination of medication along with therapy, although we don’t have enough information to judge at this point.
Moving from Cognitive Fusion to Defusion
2- A mid-twenties woman who recently gave birth to a boy who went to a dermatologist with red, dry and raw hands. She comes from a highly religious and very strict family.
• Appearance, attitude, activity – neatly dressed and fidgety
• Mood and affect – dysphoric and anxious
• Speech and language – fluent and pressured
• Thought process, thought content, perception – no suicidal or homicidal thoughts and no hallucinations but obsessed with germs, contamination and the baby’s death
• Cognition – orientation level 3 and easily distracted
• Insight and judgment – obsessive thinking and compulsive urges
This client is suffering from obsessive-compulsive disorder and again, there will be multiple ways for a practitioner to address this. In terms of your MSE notes though, it’s up to you how much detail you go into. These are just brief examples but the more detail you can go into, the more data you’ll have to use when making your diagnosis.
Mental Status Exam Softwares
With technology, practitioners have a whole new dimension to work with. As an experiential tool, digital offers more immediate opportunities for self-reflection and behavioral adjustments. You can do this by sending reminders to your client to complete exercises at specific times, for example. The Quenza platform actually does this for you automatically if you want.
The challenge with mental status exam templates is that the majority of the points need to be done in person, either physically or online. So, most online platforms for managing tests, such as the well-known Pearson’s Q-Global, wouldn’t apply to MSEs.
As you can see from the case studies above, mental status exam templates need to be managed by a practitioner. That’s not to say you can’t show your notes to your clients and in many cases, that can actually help empower clients.
Nevertheless, there are different ways to gather the separate pieces of MSE information. As we’ve mentioned, you can put together some survey questions as part of your intake form which can be sent through the Quenza platform. This can be particularly useful for the thought, cognition and insight sections.
As a result, when you explore mental status exam softwares, you want to consider how to blend digital ease along with doing a physical assessment. For instance, do you want to have a checklist in front of you as you talk to your client? Alternatively, do you prefer being able to create your own questions and split them into different forms to send your clients?
Finally, as we’ve mentioned, you’ll need to review how you’ll store and manage your clients’ mental status exam templates. Last but not least, budget is clearly something to keep in mind.
Training and Skill Acquisition for Mental Status Exams
Aside from mental status exam softwares, you can find a range of courses for completing an MSE, such as this PESI course. As they do in their course, make sure you look for providers that can offer more than just what you learnt in grad school.
Mental status exam templates aren’t just checklists to aid diagnostics. They can be the difference between noticing suicidal intentions and not. As you practice and become more expert, you’ll also see the value of filling in more information than just what the checkboxes provide.
Again, this isn’t about judging but about learning to observe the smallest details. With those details, your case formulations will become easier and more accurate. In the end, you’ll be able to offer more timely and relevant guidance to your clients.
Moreover, with no standard MSE out there, recent research urges therapists and counselors to get updated training. As a 2019 study describes [3], many in the field have focused on interview protocols and perhaps lost some of the art required for phenomenology-oriented “observational” techniques. In other words, there’s always something to improve when it comes to fine tuning observational skills.
Final Recommendations for the Mental Status Exam
Mental status exam templates are a critical part of evaluating a new client’s state of mind and ability to function. With these forms, you also gather information in a systematic way to better inform your diagnosis.
Mental status exam software now also means you can store and access everything online. Whether you print them off or refer to them on your screen during an online call is of course, up to you.
Where you can really make a difference as a practitioner, is by incorporating the MSE themes into surveys or questionnaires for your clients. Most of the MSE themes need to be done in person, physically or digitally. Nevertheless, you can get further insights by asking clients to reflect on questions as homework and to send you their answers.
As you’ve seen, you can leverage ready-made intake forms with Quenza or you can make your own forms. Either way, working with a platform like Quenza is an interactive experience where clients feel empowered.
Let’s not forget that you also get back-office support for documentation management, scheduling, billing and much more.
Don’t take our word for it. See for yourself by signing up for the free, full-access, one-month $1-only trial. You’ll have access to the whole of Quenza and you can start today with empowering your clients.
References
- ^ Rovner, B., & Synderman, D. (2009). Mental status exam in primary care: A review. American Family Physician, 80(8), 809-814.
- ^ Baker, R. B., & Trzepacz, P. (1993). The psychiatric mental status examination. Oxford University Press.
- ^ Cavalcanti, M. T., Estellita-Lins, C. E., Lessa, M. L., & Neto, H. G. R. (2019). Mental State Examination and Its Procedures—Narrative Review of Brazilian Descriptive Psychopathology. Frontiers in Psychiatry, 10. doi: 10.3389/fpsyt.2019.00077.
