Mental Status Exam
A structured mental status exam template for clinicians: appearance, behavior, speech, mood and affect, thought process and content, perception, cognition, insight, and judgment, with common descriptors and room for narrative notes.
How to use this template
The mental status exam (MSE) is a structured snapshot of how a patient presents at the time of contact. Almost everything in it is observed rather than reported; mood is the main exception, recorded in the patient's own words. The checklists below offer common descriptors to speed documentation. They are prompts, not scores. Check what fits, describe behavior concretely instead of interpreting it, and quote the patient wherever a phrase captures something a label would flatten. Context matters. Eye contact, expressiveness, and speech norms vary across cultures, and the most useful observations are often deviations from this patient's own baseline.
Appearance and behavior
Check the descriptors that fit today's presentation.
Speech
Note rate, volume, fluency, and spontaneity.
Mood, in the patient's own words
Mood is subjective. Record the patient's own description, quoted directly when possible.
Affect, as observed
Affect is what you observe: range, intensity, stability, and whether it matches stated mood and the content being discussed.
Thought process and content
Process describes how thoughts flow; content describes what they hold. Expand on anything checked in the summary, and assess and document any safety concerns according to your setting's protocol.
Perception and cognition
Cover perceptual disturbances, orientation, attention, and memory as observed or grossly screened in session.
Insight and judgment
Insight is the patient's understanding of their situation; judgment is how they weigh decisions. Note recent, concrete examples in the summary where relevant.
Summary and impressions
Pull the exam together: the overall clinical picture, anything that deviates from this patient's baseline, quotes worth preserving, and findings that shape today's plan or require follow-up.
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