Mental status exam notes. Less paperwork.
Turn the conversation and your clinical observations into a structured mental status exam draft. More presence. Less paperwork.
No credit card required. 10 free actions every month.
YOUR CLINICAL EYE. A clearer workflow.
Capture the conversation
Add your observations
Review your MSE
Every observation. A place in the picture.
Select a domain to see how a finding becomes a focused note.
Appearance & behavior
How the person presents and engages in the conversation.
Your observations
Casually dressed and engaged in the conversation.
Example note wording
Casually dressed. Engaged throughout the visit.
Speech
The pace, volume, and clarity of the conversation.
Your observations
Speaks clearly and at an even pace.
Example note wording
Clear speech at an even pace.
Mood & affect
Their words about how they feel, alongside your observations.
Their words + your observations
“I feel more settled.” Relaxed during the conversation.
Example note wording
Mood: “more settled.” Affect: relaxed.
Thought process
How ideas connect as the conversation unfolds.
Your observations
Answers follow the questions and stay on topic.
Example note wording
Answers are organized and stay on topic.
Thought content
The topics and priorities discussed during the visit.
Their words
“I’d like to get back into a daily routine.”
Example note wording
Focus: getting back to a daily routine.
Perception
A dedicated place for experiences discussed during the visit.
Your template
Add the experiences discussed and your observations.
Example note wording
Perception: [your notes]
Cognition
Your notes on attention, orientation, and memory.
Your template
Add your attention, orientation, and memory observations.
Example note wording
Cognition: [your notes]
Insight & judgment
Understanding and decision-making, in your own words.
Your template
Add your notes on understanding and decisions discussed.
Example note wording
Insight & judgment: [your notes]
Read all 8 MSE domains and examples
Appearance & behavior
How the person presents and engages in the conversation.
- Your observations
- Casually dressed and engaged in the conversation.
- Example note wording
- Casually dressed. Engaged throughout the visit.
Speech
The pace, volume, and clarity of the conversation.
- Your observations
- Speaks clearly and at an even pace.
- Example note wording
- Clear speech at an even pace.
Mood & affect
Their words about how they feel, alongside your observations.
- Their words + your observations
- “I feel more settled.” Relaxed during the conversation.
- Example note wording
- Mood: “more settled.” Affect: relaxed.
Thought process
How ideas connect as the conversation unfolds.
- Your observations
- Answers follow the questions and stay on topic.
- Example note wording
- Answers are organized and stay on topic.
Thought content
The topics and priorities discussed during the visit.
- Their words
- “I’d like to get back into a daily routine.”
- Example note wording
- Focus: getting back to a daily routine.
Perception
A dedicated place for experiences discussed during the visit.
- Your template
- Add the experiences discussed and your observations.
- Example note wording
- Perception: [your notes]
Cognition
Your notes on attention, orientation, and memory.
- Your template
- Add your attention, orientation, and memory observations.
- Example note wording
- Cognition: [your notes]
Insight & judgment
Understanding and decision-making, in your own words.
- Your template
- Add your notes on understanding and decisions discussed.
- Example note wording
- Insight & judgment: [your notes]
What they say. What you see. Both belong.
Keep the patient’s words and your observations distinct. Add the details only you can see, then review them together in the draft.
A mental status exam example. From observation to note.
One conversation. Your observations. A note that reads the way you want.
ENCOUNTER INPUT
“I feel more settled. I’d like to get back into a daily routine.”Patient report
Your observations
- Casually dressed and engaged in the conversation.
- Clear speech at an even pace.
- Relaxed expression. Answers stay on topic.
STRUCTURED MSE DRAFT
- Appearance & behavior
- Casually dressed. Engaged throughout the visit.
- Speech
- Clear speech at an even pace.
- Mood & affect
- Mood: “more settled.” Affect: relaxed.
- Thought process
- Answers are organized and stay on topic.
- Thought contentYour wording
- Focus: daily routine.
- Perception
- Perception: [your notes]
- Cognition
- Cognition: [your notes]
- Insight & judgment
- Insight & judgment: [your notes]
Make the wording yours.
A quick edit adds the detail you want to carry forward.
See the MSE note
- Appearance & behavior
- Casually dressed. Engaged throughout the visit.
- Speech
- Clear speech at an even pace.
- Mood & affect
- Mood: “more settled.” Affect: relaxed.
- Thought process
- Answers are organized and stay on topic.
- Thought content
- Focus: getting back to a daily routine.
- Perception
- Perception: [your notes]
- Cognition
- Cognition: [your notes]
- Insight & judgment
- Insight & judgment: [your notes]
- Your words
- Your observations
- Your preferred format
Your questions, answered.
Can I use my own mental status exam template?
Yes. Set up your preferred MSE headings and note structure with a custom template, then make the wording your own.
How do I add my observations?
Type or dictate your observations and keep them alongside the conversation in your MSE draft.
How does an MSE note fit into my workflow?
Capture the conversation, add your observations, and bring the details together in your chosen template. Edit the draft, then move the finished note into your record.
Can I edit the wording and headings?
Yes. Adjust the language, reorganize sections, and keep the headings that work for your documentation style.
How do I move the finished note into my EMR?
Copy or export your finished note from Vero into your existing EMR workflow.
Be present for the person. Let the note take shape.
Your observations. Your judgment. A little less paperwork.
No credit card required. Start with the free plan.