Mental Status Exam (MSE) Template and Examples

The mental status exam is the observational part of a psychiatric or psychological assessment. History tells you what has happened; the MSE tells you how the client is functioning in the room today. Clinicians complete a full MSE at intake, in a crisis, before and after a change in medication or level of care, and whenever the presentation changes. Many progress notes carry a short MSE in the Objective or Data section.

A clear MSE does three jobs. It gives a baseline you can compare future sessions against, it supports the diagnosis and the risk formulation, and it lets a covering clinician recognize a change quickly. Because it is a snapshot, the MSE should describe only what you saw and heard during this contact, and it should say so when a domain was not assessed.

The MSE is usually one section of a larger document. See the intake assessment template for where it sits in a first-session evaluation, and the biopsychosocial assessment template for the full history that surrounds it.

Published reviews group the exam into the same core domains, though the order varies by setting. The template below follows the order used in most behavioral health records:

1. Appearance: grooming, hygiene, dress, apparent age, notable physical features.
2. Behavior and motor activity: eye contact, cooperation, posture, psychomotor agitation or slowing, unusual movements.
3. Speech: rate, volume, rhythm, spontaneity and coherence. The form of speech matters more than the content here.
4. Mood: the client's own description of how they feel, ideally quoted.
5. Affect: the emotional expression you observe: range, intensity, stability and whether it fits the mood and content.
6. Thought process: how thoughts are organized and connected (linear, circumstantial, tangential, loose).
7. Thought content: what the client is thinking about, including preoccupations, obsessions, delusions and suicidal or homicidal ideation.
8. Perception: hallucinations or other perceptual disturbances, and whether the client appears to be responding to internal stimuli.
9. Cognition: orientation, attention, concentration and memory, plus any screening instrument used.
10. Insight: the client's awareness of their difficulties and need for help.
11. Judgment: the client's ability to anticipate the consequences of their choices.

The distinction clinicians most often blur is mood versus affect. Mood is the client's subjective emotional state as they report it; affect is your observation of the emotion they express. Thought process versus thought content is the second: process is how the client thinks, content is what they think about.

Use descriptive words that another clinician would interpret the same way, then add one concrete observation. The table lists terms in common use for the domains that cause the most variation between writers.

Avoid shorthand that only you understand, and avoid words that carry judgment rather than information. "Client was difficult" tells a reader nothing; "client declined to answer questions about substance use and asked twice when the session would end" does.

Most progress notes do not need a full exam. A one or two sentence MSE in the Objective section of a SOAP note or the Data section of a DAP note is enough when nothing has changed: "Alert and oriented, casually dressed, cooperative. Mood 'tired,' affect constricted but reactive. Speech and thought process normal. Denies SI/HI, no perceptual disturbances." Expand any domain that changed since the last session, and always record the risk questions you asked and the answers you received.