MENTAL STATUS EXAMINATION — ADULT ENCOUNTER
Patient / encounter:
Examiner and role:
Assessment date / start and end time / entry time:
Setting: in person / video / telephone:
Language / interpreter / communication or sensory support:
Sources: patient / direct observations / named collateral / dated records:
Visibility, connection, participation or other assessment limits:

APPEARANCE AND BEHAVIOR
Relevant observed dress, self-care, posture and engagement:
Motor activity / movements / gait if observed:
Patient explanation or contextual factors:

SPEECH
Rate / volume / articulation / amount / pauses or interruptions:
Language or connection factors affecting interpretation:

MOOD AND AFFECT
Patient's own description of mood and time period:
Observed emotional expression / range / reactivity / supporting examples:

THOUGHT PROCESS
Organization and connections between ideas:
Specific speech example if describing an abnormality:

THOUGHT CONTENT
Themes, worries or beliefs explored; patient's words:
Conviction, context and impact where relevant:
Thoughts of death, self-harm or harm to others: questions, timeframe and responses:
Broader safety assessment / formulation record reference:

PERCEPTION
Experiences asked about, modality, timing and patient's description:
Behavior observed during the encounter, recorded separately:
Unexplored areas / clarification needed:

COGNITION
Alertness and attention during the encounter:
Orientation questions actually asked and responses:
Memory or other tasks used / responses / conditions:
Instrument, version, language and result if administered:
Functions not assessed and reason:

INSIGHT AND JUDGMENT
Person's understanding of difficulties and views on help:
Specific decision discussed / reasoning / relevant behavior:
Separate decision-specific capacity assessment reference, if needed:

INTERPRETATION AND FOLLOW-UP
Summary supported by this encounter:
Differences from baseline; source and date of comparison:
Uncertainty / missing information / effect on interpretation:
Action taken or planned / responsible clinician / review time:
Urgent response and actual handoff, when applicable:
Author / authentication / required supervision:
Saved narrative and structured MSE fields checked for agreement: