A mental status exam (MSE) records how a patient presents during one interview, domain by domain, from appearance and speech to thought, cognition, insight, and judgment. Copy the free template, see a normal outpatient exam and an exam in acute mania, and check the normal and abnormal words for each domain.
Blank mental status exam template
FreeMENTAL STATUS EXAM Patient: [Name, age] Date and time: [Date, start time, minutes observed] Setting: [Outpatient, inpatient unit, emergency department, home, or video] Examiner: [Name, credentials] Reason for exam: [New assessment, follow-up, change in presentation, or daily review] Last exam for comparison: [Date, or none] APPEARANCE Age and build: [Looks stated age, older, or younger; thin, average, or heavy build] Dress and grooming: [Well groomed and dressed for the setting, or disheveled, unclean, or unusual for the weather] Notable features: [Scars, injuries, tattoos, odor of alcohol, signs of self-neglect, or none] BEHAVIOR Attitude to examiner: [Cooperative, guarded, suspicious, hostile, withdrawn, or overfamiliar] Eye contact: [Good, poor, fleeting, or intense] Psychomotor activity: [Normal, slowed, or agitated, with what you saw: pacing, fidgeting, rocking] Abnormal movements: [None, or tremor, tics, dyskinesia, posturing, or other catatonic signs] SPEECH Rate and amount: [Normal, slow, rapid, pressured, or poverty of speech] Volume and tone: [Normal, soft, or loud; varied or monotone] Articulation and fluency: [Clear and fluent, slurred, or word-finding pauses] Ease of interruption: [Easily interrupted, or hard to interrupt] MOOD AND AFFECT Mood: [The patient's own words, quoted] Affect: [Euthymic, dysphoric, anxious, irritable, or euphoric] Range and stability: [Full, restricted, blunted, or flat; stable or labile] Congruence: [Congruent or incongruent with the stated mood and the topic] THOUGHT PROCESS Form: [Linear and goal-directed, circumstantial, tangential, flight of ideas, loose associations, or thought blocking] Example: [A short quote that shows any abnormal form] THOUGHT CONTENT Main themes: [Preoccupations, worries, ruminations] Delusions: [None, or type: persecutory, grandiose, referential, somatic; how firmly held] Obsessions and phobias: [None, or content] Suicidal ideation: [None, passive, or active; intent, plan, preparation, access to means; time frame asked about] Homicidal ideation: [None, or target, intent, plan, access to weapons] PERCEPTION Hallucinations: [None reported, or modality, content, frequency, commands] Observed behavior: [Not responding to internal stimuli, or what you saw: pausing, glancing, muttering] Other experiences: [Illusions, depersonalization, derealization, or none] COGNITION Level of consciousness: [Alert, drowsy, or fluctuating] Orientation: [Person, place, date, situation] Attention: [Months backward, serial 7s, or digit span, with the result] Memory: [3-word recall at 5 minutes; recent events] Screening score: [MoCA, Mini-Cog, or other, with score, or not done and why] INSIGHT Insight: [Good, partial, or poor, with the patient's own explanation of the problem] JUDGMENT Judgment: [Good, fair, or poor, with a recent real decision as evidence] SUMMARY Key findings: [The abnormal findings in one or two lines, or normal exam] Change since last exam: [Better, worse, or unchanged, and how] Action: [Safety steps, changes to the plan, and who was told] Signed: [Name, credentials, date and time]
Use it for
Each one follows the template. Use them to judge how much detail every part needs.
Outpatient psychiatry, routine medication review, in person, 20 minutes
61-year-old woman with recurrent major depressive disorder, in full remission for 18 months on sertraline. Routine 6-month review, seen alone. Compared with her exam at the last review, 6 months ago.
Looks her stated age. Neatly dressed for the weather, well groomed. Relaxed and seated comfortably throughout. Warm and cooperative, with good eye contact. No psychomotor slowing or restlessness. No tremor or abnormal movements.
Normal rate, volume, and amount. Clear and fluent, with varied tone. Easily interrupted; took turns naturally.
Mood: “Pretty good, honestly. Steady.” Affect euthymic, full range, and reactive: laughed telling a story about her grandson, and grew serious talking about her brother’s recent heart surgery. Congruent with her stated mood and with each topic.
Linear and goal-directed. Answered each question directly, with no prompting needed to return to the topic.
Themes: her brother’s recovery, and a trip in March to see her daughter. No delusions, obsessions, or excessive worry. Asked directly, for today and since the last visit, about thoughts of death, wishing not to wake up, suicide, and self-harm: none. No thoughts of harming others.
Asked about voices, visions, and other unusual sensory experiences: none. Not observed responding to internal stimuli.
Alert. Oriented to person, place, date, and the reason for the visit. Said the months of the year backward without error. Recalled 3 of 3 words at 5 minutes. Manages her own medicines and finances.
Insight good: names her early warning signs, waking at 4 a.m. and dropping her morning walks, and would call the clinic if they came back. Judgment good: kept taking sertraline through her brother’s illness, and raised tapering with her psychiatrist instead of stopping on her own.
Normal mental status exam, unchanged from 6 months ago. PHQ-9 3. No safety concerns. Discussed tapering: given her past episodes, she chose to stay on the current dose and revisit it at the next review, in 6 months.
Inpatient psychiatry unit, day 2 of admission, morning review
36-year-old man with bipolar I disorder, admitted yesterday with mania. Stopped lithium 8 weeks ago because he “felt flat.” Slept about 1 hour a night for 6 nights before admission, per his partner. Urine drug screen negative at admission. Seen for 25 minutes with a nurse present. Compared with his admission exam yesterday.
Looks his stated age. Bright patterned shirt buttoned unevenly, three watches on one wrist, unshaven, strong smell of cologne. Paced the room and sat for less than a minute at a time. Overfamiliar: used the examiner’s first name and offered a share in his new business. Picked up papers from the desk twice; put them back when asked. Intense eye contact. No tremor or abnormal movements.
Pressured, loud, and rapid. Hard to interrupt: talked over two attempts to ask the next question, and stopped only when the nurse raised a hand. Frequent puns and rhymes. Articulation clear.
Mood: “Unbelievable. Best I’ve ever felt.” Affect euphoric and expansive, and labile: shouted when told his phone stays at the nursing station overnight, then laughed and apologized within seconds. Congruent with his stated mood.
Flight of ideas, linked by sound and association: “I quit the bank, banks of a river, rivers run to the sea, so I’m buying a boat, Lisbon in May, Lisbon has the best tiles, I could import tiles…” Answered for a sentence or two when redirected, then drifted again.
Grandiose delusion: believes the tile-import business he started 4 days ago will earn “ten million by summer,” and that a well-known chef has asked to partner with him. Nothing supports this, and he holds it with full conviction. No persecutory ideas or ideas of reference. Asked directly, for today and the past week, about thoughts of death, suicide, and self-harm: none. “Why would I? Life’s perfect.” No thoughts of harming others, and no threats on the unit. No firearms at home, per his partner.
Denies hallucinations of any kind when asked. Not observed responding to internal stimuli; nursing notes record none overnight.
Alert. Oriented to person, place, and date. Began the months backward correctly, but lost track at August after turning toward a noise in the corridor, and could not finish with two prompts. Registered 3 words; recalled 2 of 3 at 5 minutes. Attention too poor today for a valid cognitive screen; repeat once he is less distractible.
Insight poor: does not think he is unwell. “The only problem is everyone else is slow.” Calls the admission his partner “panicking,” though he takes the medication offered. Judgment poor: quit his job by email 5 days ago and paid a $6,000 deposit on a boat, per his partner. Tried to leave the unit barefoot at 2 a.m., per nursing, and came back with staff.
Manic episode with a grandiose delusion: pressured speech, flight of ideas, euphoric and labile affect, marked distractibility, and poor insight and judgment. No suicidal or homicidal ideation; no hallucinations. Since admission: slept 3 hours last night, up from about 1, per nursing; speech a little easier to interrupt; YMRS 33, down from 36. Continue 15-minute observations and a low-stimulation room. Lithium restarted at admission; first level due 5 days after the restart, 12 hours after the evening dose. Discussed with the team at rounds.
What anyone in the room could see: how the patient looks, and how they act and move during the interview.
Avoid: “Appears anxious” on its own. That is your inference. Write what led you to it: wringing hands, watching the door, sitting on the edge of the chair.
How the patient talks, not what they say.
Avoid: Calling fast speech “pressured.” Pressured speech is driven and hard to stop; write down what happened when you tried to interrupt.
Mood is how the patient says they feel, in their words. Affect is the emotion you see, and how it moves during the interview.
Avoid: “Mood and affect euthymic” as one entry. It loses both the patient’s own words and what you observed.
How the patient’s thoughts connect, heard in the way their answers flow.
Avoid: A label with no example. One quoted sentence lets the next reader judge the term for themselves.
What the patient is thinking about: main themes, abnormal beliefs, and thoughts of harm. Ask about harm in every exam, including a normal one.
Avoid: “No SI or HI” with no time frame. Say what you asked, and whether the answer covers today or the time since the last visit.
Experiences without an outside source, and whether the patient seems to be responding to them now.
Avoid: “No hallucinations” when you didn’t ask. Record the question, and keep what you observed apart from what the patient reported.
Alertness, orientation, attention, and memory, with the tasks you used. Conversation alone shows only part of this.
Avoid: Reading poor recall as memory loss in a patient who couldn’t attend. In mania, severe anxiety, or psychosis, note that attention limited the test, and repeat it later.
Insight is how well the patient understands their condition and the need for help. Judgment is how they make decisions, shown by what they have actually done.
Avoid: A hypothetical test, such as what to do with a found letter. A real decision from the past week says far more.
The exam in two or three lines, so a busy reader gets the point first.
A normal exam still says something: how the patient looked, their mood in their words, that you asked about suicide and hallucinations, and how you tested cognition. Write it out, as in the outpatient example.
The MSE is a snapshot of one interview. A copied exam hides change, and can record a calm patient on the day they paced the room. Write today’s findings, and say what changed.
“Bizarre,” “odd,” and “inappropriate” mean different things to different clinicians. Pair each with the behavior or the quote behind it.
Poor judgment in the MSE doesn’t mean a patient lacks capacity for a specific decision. Capacity needs its own assessment of that decision, at that time.
Vero Scribe drafts the mental status exam in your template from the interview, with the patient’s consent, or from your dictation of what you observed. You review and edit every domain, then copy the exam into your record or export it to Word or PDF. Vero works in 60+ languages.
Most clinicians follow the same order: appearance, behavior, speech, mood and affect, thought process, thought content, perception, cognition, insight, and judgment. Thought content includes suicidal and homicidal ideation. The template follows that order.
Write a short line for each domain, even when nothing is abnormal: “Well groomed, cooperative, good eye contact. Normal speech. Mood ‘good’; affect euthymic, full range. Linear thought process. No suicidal or homicidal ideation; no delusions. No hallucinations. Alert and oriented, recall 3 of 3. Insight and judgment good.” The outpatient example shows the full version.
Mood is the emotion the patient reports, recorded in their words. Affect is the emotion you observe in their face, voice, and posture, and how it changes. When they differ, such as “fine” said with a flat, tearful affect, that is a finding worth recording.
No. The MMSE, or Mini-Mental State Examination, is a 30-point cognitive screening test. The mental status exam is the whole exam, from appearance to judgment. A cognitive screen such as the MMSE, MoCA, or Mini-Cog is recorded under cognition.
Yes. Copy it, or download it as a Word or text file. No account needed.
The full first psychiatric assessment, with a structured mental status exam and a risk formulation.
Follow-up and medication management visits, tracked by target symptoms, side effects, and risk.
The psychiatrist’s ED or ward consult: the question, sources, medical contributors, MSE, risk, capacity, and numbered recommendations.
The written assessment of an adult referred for possible ADHD: symptoms, childhood onset, scales, differential, and plan.
The longer read: choosing words that match the evidence, an exam by video with a limited view, and a draft to correct.
How Vero turns the interview and your observations into an MSE draft.
Evaluations, follow-ups, and mental status exams, drafted for your review.
Scoring and bands for the mania rating in the inpatient example.
The codes used most often in psychiatry.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
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