Mental Status Exam: Structured Checklist and Documentation Examples

A mental status exam (MSE) describes a person’s mental functioning during a clinical encounter. It combines what the clinician observes, what the person reports and the responses to questions or tasks. Common headings cover appearance and behavior, speech, mood and affect, thinking, perception, cognition, insight and judgment.

In mental health care, the terms mental state exam and mental status examination are commonly used for this assessment. This guide covers adult encounters. Start with the domain checklist, a completed example or the blank template.

Sources checked: November 2, 2026.

Mental status exam checklist

Record the date, assessment period, examiner, setting and communication support first. A face-to-face interview, a cropped video image and a telephone call provide different opportunities for observation. Note pain, fatigue, hearing difficulties or interruptions that affected participation.

This adult checklist follows the domain structure in NHS Greater Glasgow and Clyde’s MyPsych teaching resource. Adjust the depth of assessment to the presentation and your role. Complete each field with the findings from the encounter.

On a small screen, scroll the table sideways to see the examples.

The cognitive fields deserve separate attention. Following a conversation provides some information about attention, but recall, orientation and other functions need their own evidence. Open RN’s mental status assessment table distinguishes consciousness and orientation from cognitive abilities. If a task was not performed, say so. If a standardized instrument was used, record its name, version, language, conditions and result in the appropriate assessment record.

Choose words that match the evidence

Mood and affect need separate entries. A person can describe feeling miserable and smile briefly during the interview. Record both. A single smile gives little information about the rest of the day. “Reactive” describes a change in emotional expression during the discussion; “flat” describes markedly absent expression. Use either term with the behavior that led you to it. The University of Edinburgh’s teaching module on mood and perception explains the subjective emotional account and observed affect.

Thought process and thought content answer different questions. A person may describe an unusual belief in an organized way. Another may talk about ordinary events but repeatedly lose the connection between ideas. Record an example of the speech before assigning a term such as tangential or circumstantial. Circumstantial speech eventually reaches the point after excess detail; tangential speech moves away from the question without answering it.

Write behavior that another reader could recognize. “Declined to discuss alcohol use and asked why the question was relevant” is more informative than “uncooperative.” “Looked toward the doorway twice” records an observation. Its cause still needs exploration. Likewise, disagreement with a proposed treatment does not, on its own, describe the person’s understanding or decision-making abilities.

Ask how the person explains the experience, including relevant cultural or spiritual context. Use the preferred language and appropriate communication support. Record interpreter involvement and any resulting limits on interpreting speech. The APA Cultural Formulation Interview explores the person’s own account, context and sources of support.

MS-01: a completed outpatient mental status exam

MS-01 is fictional.

Information available to the writer

Riya, 32, attends an adult outpatient appointment on November 2, 2026. Dr. Lane conducts an English-language, face-to-face interview from 10:00 to 10:25. No interpreter is used. The room is quiet and the full seated presentation is visible.

• Riya wears clean clothing suitable for the weather, remains seated and answers questions. They twist a tissue when describing work and request a short pause. Gait is not assessed.
• Speech is quiet but audible, clearly articulated and at a conversational rate. Riya gives relevant answers, with one reminder to return to the question after discussing a deadline.
• Riya says, “I’ve felt worried most days for two weeks.” They become tearful while discussing work and smile when describing support from their sister.
• Riya worries that their manager might dismiss them. When asked, they explain that no dismissal decision has been communicated. They describe this as a fear.
• Asked about hearing voices or seeing things others do not perceive, Riya reports no such experiences during the interview or the preceding two weeks. Other sensory experiences are not explored in this part of the assessment.
• Asked directly about thoughts of death, self-harm or harming others now or during the preceding two weeks, Riya reports none. The broader safety assessment, relevant history and clinical formulation are recorded separately in MS-R1, completed by Dr. Lane at 10:35.
• Riya is awake throughout and follows the conversation. They correctly state their name, the clinic, the date and the purpose of the appointment. No formal attention, memory or other cognitive test is administered.
• Riya links worsening sleep with worry and asks about help. They report arranging for their sister to drive because they had slept poorly. Dr. Lane has not conducted a decision-specific capacity assessment.
• After completing the wider assessment, Dr. Lane and Riya agree to a review on November 9 at 10:00, booked before departure. The care plan and earlier-contact instructions are recorded in MS-P1.

Finished MSE entry

November 2, 2026. Assessment 10:00–10:25; entry 10:40. Dr. Lane. Face-to-face adult outpatient interview in English, without an interpreter. Sources: Riya’s account and direct observation.

Appearance and behavior: clean clothing suitable for the weather. Seated and engaged with questions; twisted a tissue when discussing work and requested a pause. Gait not assessed. Speech: quiet but audible, clear articulation and conversational rate. Mood: “worried most days for two weeks.” Affect: anxious and tearful during discussion of work, with a smile when discussing support from sister; expression changed with the topic.

Thought process: relevant, organized answers; returned to the question after one reminder. Thought content: worry about possible job loss; Riya states that no dismissal decision has been communicated. Reports no thoughts of death, self-harm or harming others now or in the preceding two weeks. Broader safety history and formulation: MS-R1, completed at 10:35. Perception: reports no auditory or visual experiences of the kind asked about during the interview or preceding two weeks; other modalities not explored here.

Cognition: awake and able to follow the interview. Correctly states name, clinic, date and purpose of visit. Formal attention, memory and other cognitive testing not performed. Insight: associates poor sleep with worry and requests help. Judgment: reports arranging a lift after poor sleep. Decision-specific capacity not assessed in this encounter.

Review booked for November 9 at 10:00 with Dr. Lane. See MS-P1 for the agreed plan and earlier-contact instructions.

Riya’s description of worry belongs under mood; the tearfulness and smile belong under affect. The note records the orientation questions answered and leaves formal memory testing unassessed. MS-R1 and MS-P1 contain the safety formulation and care plan.

The biopsychosocial assessment guide shows how current findings fit alongside history and a broader formulation. For session interventions and responses, use the appropriate progress-note structure, such as BIRP.

Document a later clarification

At 10:50, before leaving, Riya tells Dr. Lane: “Last night, just as I was falling asleep, I thought I heard my name.” Dr. Lane asks about the timing and whether it is happening now. Riya reports one brief experience around sleep onset and none during the visit. These details were not available for the 10:40 entry.

An update could read:

10:55, Dr. Lane: Riya adds a report of briefly hearing their name around sleep onset last night. Reports no recurrence while awake and no current experience. Timing and circumstances clarified in person at 10:50. Cause undetermined. Dr. Lane will revisit it at the booked November 9 review; earlier-contact instructions reviewed with Riya.

Keep the original account and add the clarification at the time it was received. Attribute the experience to Riya’s report about the previous night. When another person provides information, include their identity or role, what they observed, and when. The collateral-information guide covers conflicting accounts and source attribution in more detail.

MS-02: a video encounter with limited observation

This second example is fictional. At 14:00, clinician Noor begins a video appointment with Evan. Only Evan’s face and shoulders are visible. The audio repeatedly freezes during answers. Evan says, “The sound keeps cutting out.” At 14:07, they reconnect by telephone using the verified callback number. Noor confirms the current location and agreed local emergency contact procedure under the service’s telehealth process.

The telephone portion continues until 14:20. After reconnection, Noor hears Evan’s answers clearly; they address the questions without the earlier audio gaps. Evan says, “I’m frustrated with the connection.” Noor defers formal cognitive testing because of the interrupted assessment conditions. Noor and Evan agree to complete the remaining assessment in person on November 4 at 09:00. Noor books that appointment and confirms the date and time with Evan before ending the call.

The original draft says: “Long response latency, poor concentration, normal gait and no abnormal movements.” None of those conclusions follows from the available view and unreliable audio.

A more accurate entry is:

14:00–14:07 video; 14:07–14:20 telephone. Noor. Initial image showed face and shoulders only; gait and whole-body movements were not visible. Repeated audio interruptions prevented assessment of response latency during the video portion. After telephone reconnection, Evan gave audible, relevant answers without the earlier gaps. Evan reports frustration with the connection. Visual assessment of affect and movement was unavailable after 14:07. Formal cognitive testing deferred because of interrupted assessment conditions. Noor will complete the remaining assessment at the agreed in-person visit on November 4 at 09:00; appointment confirmed with Evan.

Use the reliable telephone answers to describe speech and keep cognitive testing marked as deferred. Record any interpreter or hearing support used and how it affected the interview.

Practice: correct an MSE draft

Use MS-01 as it stood at 10:40, before the later disclosure:

Cooperative. Mood and affect normal. Thought disorder because patient worries about dismissal. No hallucinations. Memory intact. Judgment good; has capacity. Low risk because calm.

Identify which statements have evidence, which overstate it, and which questions were not assessed. Then open the answer.

Reveal the MS-01 documentation review

• Engagement: describe answering questions and requesting a pause. “Cooperative” alone omits those details.
• Mood and affect: preserve Riya’s report of worry and the observed tearfulness and smile.
• Thinking: record relevant answers under process and fear of dismissal under content. The supplied conversation gives no basis for calling this a thought disorder.
• Perception: name the auditory and visual questions and their timeframe. Other modalities were not explored.
• Cognition: orientation was assessed; formal memory testing was not performed.
• Judgment and capacity: retain the reported driving decision. The source contains no decision-specific capacity assessment.
• Safety: record the actual responses and the separate MS-R1 formulation. Calm behavior does not supply a risk conclusion.

Revised excerpt: Riya describes feeling “worried most days for two weeks”; tearful about work and smiles when discussing sister’s support. Answers are relevant and organized, with one redirection. Concerned about possible dismissal but states no decision has been communicated. Reports no auditory or visual experiences of the kind asked about during the encounter or preceding two weeks. Correctly states name, clinic, date and visit purpose; formal memory testing not performed. Reports arranging a lift after poor sleep. See MS-R1 for the safety formulation. Capacity was not assessed.

Copyable mental status exam template

Copy the blank prompts or download the matching editable text file. Add the findings from the encounter, including the questions or tasks that support them. Use the same assessment period when comparing the narrative with structured MSE fields.

For example, if the narrative says “memory testing not performed” but a structured field says “memory normal,” resolve that mismatch before signing. If a field cannot represent “not assessed,” follow the record system’s approved correction process and make the limitation visible to the next reader. The medical charting software guide includes related checks for narrative and structured records.

Safety assessment and change from baseline

The MSE contributes to the wider psychiatric evaluation. History, functioning, medication and substance exposure, physical health and collateral information may change the interpretation of the same observed behavior. The APA’s adult psychiatric evaluation guideline, published in 2015 and still listed on its current resource page, places the examination within that broader evaluation.

Record the actual questions about harm, the patient’s responses and the clinician’s resulting assessment and action. A checklist of MSE domains is not a suicide-prediction score. For people who have self-harmed, NICE NG225, section 1.6, advises against using risk scales or global low/medium/high categories to predict future suicide or determine discharge. Document the person’s needs, safety formulation and care plan in the relevant record. If there is an immediate danger, activate the service’s urgent response process while arranging assessment; completing a note can wait.

Sudden or fluctuating inattention, altered alertness or confusion also needs prompt clinical assessment. Ask about the person’s baseline and the timing of the change. NICE’s delirium guidance for hospitals and long-term care addresses recent changes over hours or days, including reports from relatives or carers, and assessment with an appropriate validated tool. Keep the medical assessment and escalation record connected to the mental-state findings.

Mental state may change between appointments. Someone may report symptoms outside the interview that are not visible during it. Retain both accounts with dates, sources and circumstances. Follow-up notes should say what changed and what action followed. The mental-health documentation workflow guide discusses transferring those updates into the receiving record.

Mental status exam documentation checklist

Before signing, check that:

• The examination time, entry time, examiner and encounter mode are recorded.
• Patient reports, direct observations and collateral accounts have clear sources.
• Mood and affect have their own evidence; process and content are distinguishable.
• Any technical term has enough supporting detail for another clinician to understand it.
• Cognitive findings match the questions or tasks performed; unassessed areas remain explicit.
• Language, cultural context, sensory needs and connection limits are described where relevant.
• Safety concerns have a documented assessment and response, with a reference to the broader formulation where needed.
• Follow-up has a responsible clinician and agreed timing, and later entries preserve the earlier account.
• Structured fields and the saved narrative agree.

For AI-assisted note preparation, see Vero’s mental status exam workflow. Supply the observations yourself, review the draft against the encounter and correct unsupported findings before using it in the clinical record.