Mental Status Exam (MSE)
A structured mental status exam template covering appearance, behavior, speech, mood and affect, thought, cognition, insight, and judgment, with a PDF you can file.
About this tool
The mental status examination (MSE) is the psychological equivalent of the physical exam: a structured, systematic description of a client's presentation at a single point in time. Where the history tells you what the client reports, the MSE documents what you observe and elicit during the interview. It is a core part of assessment, supports diagnosis, establishes a baseline against which change can be measured, and is a standard component of clinical documentation.
The exam covers a consistent set of domains. Appearance and behavior describe grooming, dress, psychomotor activity, and attitude. Speech captures rate, volume, and fluency. Mood is the client's stated emotional state, while affect is your observation of its range, intensity, and congruence. Thought process describes the form and flow of thinking (linear, tangential, disorganized), while thought content covers what the client is thinking about, including any delusions, obsessions, or suicidal or homicidal ideation. Perception covers hallucinations and other disturbances.
Cognition is assessed through orientation, attention, memory, and, where indicated, abstraction and fund of knowledge. Insight is the client's awareness of their own condition, and judgment is their capacity to make sound decisions. Together these domains give a precise, shareable snapshot. Good MSE documentation uses specific descriptive language: 'affect constricted and incongruent with stated euthymic mood' tells another clinician far more than 'affect normal.'
The MSE is a description, not a diagnosis, and it reflects only the moment of the exam. Record findings even when they are unremarkable, since a documented normal exam is clinically meaningful. Repeat the MSE over time to track change, and always document any safety-relevant findings, such as suicidal ideation or command hallucinations, and the action taken.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed, text revision (DSM-5-TR). American Psychiatric Association Publishing; 2022.
- American Psychiatric Association. Practice Guidelines for the Psychiatric Evaluation of Adults. 3rd ed. American Psychiatric Association Publishing; 2016.
Mental Status Exam (MSE) FAQ
What is a mental status exam?
A structured description of a client's presentation at a point in time, covering appearance, behavior, speech, mood and affect, thought process and content, perception, cognition, insight, and judgment. It documents what the clinician observes, as distinct from the client's reported history.
What is the difference between mood and affect?
Mood is the client's own description of their emotional state, recorded in their words. Affect is your observation of the outward expression of emotion, including its range, intensity, reactivity, and whether it is congruent with the stated mood.
Should I document an MSE even if everything is normal?
Yes. A documented normal exam is clinically meaningful, establishes a baseline, and lets you track change over time. Record each domain using specific descriptive language rather than vague summaries.
Is anything I type stored here?
No. The template runs entirely in your browser. Nothing is uploaded or saved, and the PDF is generated on your own device. Store completed exams in a HIPAA-compliant system.