Mental Status Exam Template
Get the most out of your patient’s mental status exam using our concise and customizable MSE template for psychiatrists, psychotherapists, or mental health professionals.
What is a Mental Status Exam?
A mental status exam (MSE) is a commonly used tool across mental health fields such as psychiatry, clinical psychology, and neurology, to assess a patient’s current mental state. The MSE, along with information gathered from medical and psychological histories, serves as an important part of a mental health assessment. Additionally, the MSE provides a standardized snapshot of your patient’s mental functioning, which can be conducted multiple times to create a picture of the changes in your patient’s mental state over time. The results of the MSE help the clinician to distinguish between different diagnoses and serve as the basis for their formulation process.
Our mental status exam template is a skeleton for your MSE that simplifies the documentation process, by incorporating checkboxes and interactive spaces for your notes. A template is an incredibly useful resource to standardize your documentation process, structure your session with your patient, and save you time transcribing your patient’s answers by hand.
Printable Mental Status Exam Template
Download these templates for Mental Status Exam Template to improve your therapy intake process and HIPAA compliance.
How To Use This Free Mental Status Exam Template
Since you’ll likely be conducting mental status exams on a regular basis, we’ve kept this template simple and concise to maximize your time management. Additionally, we have included spaces for your comments, or for you to select options other than those listed, allowing you to customize this template and ensure there is a space for whatever observations you think are relevant to the MSE. To start using this template in your own practice, just follow these simple steps.
Step 1. Fill in Patient Information
Once you have downloaded the PDF mental status exam from the link on this page, the first step is to fill in your patient’s information, including their name, date of birth, optional identifier, and date of the MSE. This section is important for ensuring your MSE is attached to the correct patient, and for correctly tracking the chronology of your patient’s progress.
Step 2. Conduct Your Mental Status Examination
The mental status examination section is divided into seven main sections: observations, mood, cognition, perception, thoughts, behavior and insight, and judgment. Fill out these sections using your observations of your patient throughout the examination.
Step 3. Complete Notes and Comments
As you complete the MSE, add any comments to elaborate as needed. These comments may be useful to remember important points you wish to return to with your patient, and it’s best to note these down as soon after observing as possible.
Mental Status Exam Example (Sample)
With spaces for “other” options and comments, everyone may fill out this mental status exam template a little differently, and that flexibility is one of the benefits of using this form. While there will undoubtedly be variance between MSEs completed by different practitioners, it can still be useful to see a completed MSE in order to better understand how this form can be used in your practice. Take a look at our example mental status exam here.
Download this Mental Status Exam Example (Sample) here:
Who Can Use these Mental Status Exam Templates?
Mental status exams are commonly conducted by psychiatrists, or psychiatric residents, however, this template could also be used by a whole range of mental health practitioners with sufficient clinical expertise to conduct the MSE, such as:
- Therapists or psychotherapists
- Clinical psychologists
- Psychiatric specialists
- Psychiatric nurses
- Mental health social workers.
What is crucial is that the person conducting the MSE has the experience to closely observe their patient, and ask questions that will elucidate the answers to the MSE questions in an effective way for their patient.
This MSE template may also be used by trainees or students of the above specialties in order to improve their clinical assessment skills, however, without the clinical expertise - these student MSEs should not be used to inform significant treatment decisions without supervision from an appropriate, qualified practitioner.
Why is This Template Useful for Therapists?
Standardize your MSE process
A mental status examination is a very common tool used by therapists, and having a set template to use for conducting your MSEs will save you time, and help to standardize your practice, ensuring you give all your patients the same level of care and attention to their MSEs.
Improve your organization
Our MSE template separates different information into sections with handy checkboxes and space for comments to keep your MSE clearly set out. Organize your MSE into eight commonly used headings and ensure you don’t miss asking any important questions.
Benefits Of Using The Mental Status Exam Template
Provide Evidence to Third Parties
Several different third parties may request the results of someone’s MSE, such as insurance providers or for legal purposes. By completing your MSE in a standardized and clearly formatted template, you’ll ensure you provide coherent and shareable evidence on your patient’s behalf.
Improve the readability of your MSE
Several others in your patient’s care team may use the result of the MSE to inform their clinical decision-making for your patient, so it is crucial that your MSE can be quickly understood by others. By using our MSE template with clear headings and the ability to keep it completely digital, your colleagues will be able to quickly understand the MSE results and make the best-informed decisions for your patient.
Structure your MSE session
Another benefit of this template is that it can be used to structure the session with your patient. Work through the different sections of the MSE methodically, or jump between them, either way, the MSE template will help to structure your session and ensure you don’t miss anything.
Keep your MSE digital
Keeping your medical forms digital can have huge benefits for your patient’s data security by utilizing digital encryption techniques. Our MSE form can be downloaded, filled in, and stored completely digitally either in interactive PDF form or using the template from within Carepatron.
Effectively Track Changes Over Time
Standardizing your MSE allows you to effectively compare the changes in your patient’s mental status over time. It is important that the MSE is conducted in as similar a manner as possible to the first time in order to avoid creating artificial differences in your patient’s responses. As such, using the same template each time you conduct an MSE will help to distinguish genuine progress from other confounding variables.
Commonly asked questions
The mental status exam gathers information from five main domains; general appearance, emotions or mood, thoughts, cognition, and judgment and insight. Our mental status exam template includes items for each of these categories, spread out over eight different categories with the addition of other observations, and the perception and behavior categories.
An MSE is usually conducted during the patient’s intake interview, but can be conducted at any point during the patient’s journey to provide a snapshot of their mental functioning at that time.
The information included in a mental status exam should be information gathered from observation of the patient during the MSE session. This does not include subjective reports from your patient but does include any objective observations you make such as their affect, appearance, and response to questions.
Why Use Carepatron For Mental Status Exams?
Mental status exams contain highly sensitive patient information, so it is crucial that these documents are stored and accessed securely. Your patient can also request access to these documents, as they are part of their medical records, and this process must also be conducted securely to prevent data breaches. The strict requirements around patient health information may sound like a headache, but with state-of-the-art practice management software like Carepatron, it couldn’t be easier.
Access your documents securely from Carepatron’s mobile or desktop platforms whenever you need, and effortlessly store your patient information in our HIPAA-compliant, bank-level encrypted data storage. Carepatron also offers smart features such as AI-powered voice-to-text transcription, team calendar syncing, medical coding and billing, automated SMS or email appointment reminders, and a whole lot more including this template, and many others, which are available right from within Carepatron.