Mental State Examination Template with Examples

Mental State Examination (MSE) Template

This Mental State Examination (MSE) template is designed for psychiatrists and other mental health clinicians to document a comprehensive assessment of a patient’s mental status. It covers all 10 areas of an MSE, prompting clinicians to evaluate and record a patient’s mental health systematically.

• Includes all headings for documenting a structured MSE on a single editable template 
• Prompts under each section guide the clinician on what topics to address 
• AI automatically organises information from the session into a completed MSE for the clinician to review
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What is a Mental State Examination Template?

A mental state examination (MSE) is a vital part of a majority of psychiatric interviews. By assessing and commenting on the 10 sections of an MSE—appearance, behaviour, speech, mood, affect, thought, perception, cognition, insight and judgment—the mental health clinician documents a thorough evaluation of a patient’s psychiatric functioning and emotional health. 

Many clinicians use a mental state examination template to make the process of conducting an MSE more streamlined and efficient. A template also serves to ensure no important information is missed during the interview.

In this article, we’ll explore common challenges with conducting a mental state examination and the advantages of using a high-quality template. Then, we go through what are the 10 steps of the mental state exam and how using an AI-enabled mental status examination template can make the process faster and easier. 

Common Challenges with Mental State Exams

Most of the challenges around completing an MSE stem from a combination of three issues:

1. MSEs are usually long documents that summarise inherently complex assessments.
2. The MSE forms the basis for risk management, so contents may be subject to scrutiny (particularly in the case of involuntary treatment and detention).
3. Psychiatrists and mental health clinicians are usually completing MSEs under significant time pressures.

As a result of the above, many clinicians (particularly trainee or junior psychiatrists) find writing MSEs somewhat stressful. On the one hand, the document must be thorough, complete and accurate. On the other hand, there’s always another patient to see or crisis to attend to, adding an element of time pressure to complete documentation.

Using a complete mental state examination template is one of the most effective ways to make the process of writing an MSE faster, more accurate and less mentally taxing.      

Advantages of Using a Good MSE Template

Completing MSEs with a high-quality mental state examination template has several benefits: 

• Reduced cognitive load - Rather than remembering every aspect of the MSE, the clinician can refer to the template to guide the interview. This frees up mental energy to focus on patient observations and clinical reasoning.
• Improved efficiency and completeness - An MSE template’s structure helps to keep clinical interviews focused on pertinent issues. This can reduce overall interview time and prevent accidental omissions that the clinician needs to follow up afterward.
• Stronger medicolegal documentation - MSE templates are known to improve the quality of junior psychiatrists’ documentation. In the event of an audit or legal review, having detailed and organised observations demonstrates thorough clinical assessment and sound professional practice.
• Enhanced patient engagement - It’s exceedingly difficult to split attention between mentally tracking the process of an MSE and engaging with the patient. By using an MSE template, clinicians can focus more on the patient, which often leads to better engagement. 

Mental health clinicians are increasingly turning to AI-enabled platforms like Heidi to enhance the benefits of clinical notes templates. By automating everything from progress notes to referral letters to MSEs, Heidi is helping mental health clinicians cut their daily documentation time by an average of 2.34 hours per day. 

For a personal account from a psychiatrist, you can read how Dr. Tony Fernando used Heidi to reduce his daily documentation time from 2 to 3 hours per day to a mere 30 to 60 minutes. 

How to Write a Mental State Examination

Every MSE should address all of the 10 sections listed below. The clinician may deviate from the order of topics during the interview. However, for consistency and ease of reading, it’s recommended to maintain the original sequence in the final document. 

Below is a brief overview of each section of an MSE with an example sentence for each. Where no concern or abnormality is detected in a particular area, make a brief statement reflecting your finding, such as, “Cognition is intact with no abnormalities detected.”

1. Appearance

This section documents the patient's physical presentation, including grooming, dress, hygiene and any other notable characteristics. Include a general description of physical appearance and observations of any unusual features (such as wearing a heavy jacket in summer or indicators of poor self care).

Example - “Patient presents as a well groomed middle aged woman, dressed appropriately for the weather in clean, casual clothing.”

2. Behaviour

Document the patient’s actions, movements and general demeanour. Note any unusual motor activity, interaction style and cooperation level. Observations about posture, eye contact and response to the interview setting may be relevant, but remember that some level of distress at being in an inpatient setting, particularly involuntarily, is normal.

Example - “Patient demonstrates psychomotor agitation, frequently shifting in their chair and wringing hands. Maintains intermittent eye contact and appears somewhat guarded.”

3. Speech

Describe physical characteristics of speech such as rate, volume, tone and rhythm. Note any unusual features or disturbances in speech patterns like pressure of speech, delayed responses or word finding difficulties.

Example - “Speech is slow and quiet with increased latency of response. Normal rhythm but patient displayed some word finding difficulties.” 

4. Mood

Record the patient’s subjective description of their emotional state (ideally in their own words). Can prompt the patient to use a numbered scale to describe the severity of symptoms if needed. Use questions about interests, energy level and motivation for increased depth of assessment. Note any changes in mood throughout the day (diurnal variation).

Example - “Patient describes mood as ‘down and hopeless’ over the past two weeks, rating it as 4/10 (where 10 is the best they have ever felt). Low mood is persistent throughout the day with associated lethargy and lack of interest in previously pleasurable activities like gardening.   

5. Affect

Note observations of the patient’s emotional state expressed via non-verbal language. Consider types of emotions, range (constricted to labile), reactivity (blunted to flat to reactive) and appropriateness (congruence).

Example - “Affect is restricted in range, predominantly low and congruent with reported depressed mood.” 

6. Thought

Assess and document thought stream (eg., poverty of thought or flight of ideas), form (logical or disordered) and content (obsessions, delusions, bizarre, etc). Note any abnormalities in the patient’s thought process and any concerns about thought content (such as suicidal or homicidal ideation).

Example - “Thought process is logical and goal-directed. Rumination about health issues but no evidence of delusions or suicidal ideation.” 

7. Perception

Record any abnormalities in sensory perception, including hallucinations of any sensory type and altered bodily experiences (such as derealisation or depersonalisation).

Example - “No evidence of hallucinations. Patient reports intermittent depersonalisation, stating, ‘When I get really worried about my health sometimes it feels like I’m outside of my body looking in - almost like it’s not me’” 

8. Cognition

Assess and document the patient’s level of consciousness, orientation, attention, concentration and memory. Include results from any formal cognitive testing undertaken during the interview.

Example - “Alert and oriented to person, place, time and situation. Demonstrates intact attention and concentration with ability to correctly spell ‘WORLD’ backwards”  

9. Insight

Describe the patient’s understanding of their condition. Insight may be described as good, partial or poor. Note whether the patient can identify perceptual disturbances or high-risk thought content and if they acknowledge the possibility of a mental health problem. Locus of control (internal vs. external) may require comment and insight can be variable across domains.

Example - “Patient demonstrates good insight into their low mood, recognising the impact on daily functioning and need for treatment. Understanding of health anxiety is somewhat limited but open to exploring this further”

10. Judgment

Assess the patient’s ability to make reasonable decisions and anticipate consequences. Include observations about recent decision making and problem solving ability. Future plans for addressing current challenges or stressors may also be relevant.

Example - “Judgment appears intact as evidenced by appropriate decision making regarding work and family responsibilities. No recent history or future plans of impulsive or risky behavior.”

Mental State Examination (MSE) Template Example

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With all the competing demands in psychiatric practice, producing a ‘gold standard’ MSE for every patient is a very time consuming task. Forward-thinking clinicians are now using AI-enabled templates to write detailed, accurate and high quality MSEs in a fraction of the time of traditional methods.

Write MSEs Faster, Better with Heidi

Heidi’s advanced AI medical scribe automates the process of writing an MSE. Simply press ‘Transcribe’ at the start of your session and conduct your interview as usual, safe in the knowledge that Heidi is processing everything. When you’re done, Heidi automatically generates the MSE according to your template, ready for you to review. 

Benefits of using Heidi’s AI-powered mental state examination templates include:

• Improved accuracy - Heidi creates a full transcript of the session available so you can clarify or add details to the final document. 
• Faster documentation - Have a fully completed MSE ready to review within seconds of completing your interview.
• Better patient care - With Heidi looking after your notes, you can focus entirely on your patient, facilitating better rapport and a stronger therapeutic alliance.

Heidi is wrapped in world class safety standards and trusted by over 100,000 clinicians across 50 countries. Our Template Community contains dozens of field tested templates created specifically for psychiatrists and mental health professionals. 

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Free Mental Health State Examination Templates

Complete Mental State Examination Template

This complete mental state examination template contains all 10 sections covered in an MSE, including patient information and counselor details. The template aims to make it easier for mental health professionals to comprehensively evaluate a patient’s psychological functioning, starting from appearance to judgment.

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Mental State Examination Template - Australia

This Australia MSE template is based on the most recent guidance provided by the Queensland Centre for Mental Health Learning in collaboration with Queensland Health Mental Health staff. It includes more specific aspects of MSEs such as identifying neurovegetative symptoms and the presence of hallucinations, illusions, and delusions, etc.

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FAQs About MSE Templates

What is a mini mental state examination (MMSE)?

The MMSE is a standardised cognitive screening tool that’s different from a mental state examination. It focuses specifically on cognitive function through a series of brief tests, assessing orientation, memory, attention, language and visuospatial skills. MMSEs have been validated for particular use cases in geriatric medicine, for example in the serial monitoring of delirium or dementia over sequential visits. They are typically scored out of 30 with a subset of relevant questions to cover most of the sections of a thorough MSE. An MMSE template may be completed as part of a mental state examination or as a standalone assessment to identify individuals experiencing cognitive impairment.

How should I document a mental state examination?

If you’re wondering how to perform a mental status examination, the best practice is to follow a systematic approach that covers all 10 sections. When writing an MSE, the clinician should focus on specific, observable statements rather than interpretations. When using an AI medical scribe like Heidi, you can speak naturally during your assessment while the AI organises your observations into a structured MSE format.

Can I create my own MSE template?

Yes! Once you’re familiar with what is the structure of the mental status exam, Heidi’s template editor provides three ways to create an MSE template: 1) Supply a reference MSE and ask Heidi to turn it into a template; 2) Choose an existing mental state examination template from the community and adjust it; 3) Build your own MSE template from scratch. Find out more in our Help Centre Article, Creating Templates in Heidi.