Mental State Exam (MSE) - Australia

APPEARANCE: - [Gender and sex] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Age] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Ethnicity] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Complexion] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Height and Build] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Hair (including facial hair)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Grooming] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Unique physical attributes (including scars, tattoos, piercings, missing limbs)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Facial features (e.g. flushed face, red eyes, bruises)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Body fetor (if present)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) BEHAVIOUR: - [Eye contact] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Relevant facial expressions] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Attitude towards interviewer] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Repetitive movements (e.g. tics, pacing, fidgeting)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Gait] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Psychomotor behaviour] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Style of gesturing] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) SPEECH: - [Rate] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Volume] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Tone] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Other unique qualities] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Stutter] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Accent and dialect] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Amount of speech] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Speech impediments] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Use of vocabulary] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Is the person difficult to understand?] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Presence of frequent, noticeable pauses] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) MOOD: - [How the person is feeling?] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Reported emotion] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Reported depth] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Reported duration] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Reported degree of fluctuation] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) AFFECT: - [Describe affect or how the person appears to be feeling based on their non-verbals] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Range (full, restricted)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [What emotions does the person express?] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Are these emotions appropriate to the topic?] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Intensity (exaggerated, normal, blunted, flat)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Reactivity (fixed, reactive, labile)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Congruence (congruent, incongruent)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Is the person’s affect consistent with their reported mood?] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Neurovegetative symptoms - [Sleep] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Appetite] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Weight gain/loss] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Motivation] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Interest in activities (including anhedonia)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Energy levels] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Libido] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) PERCEPTION: - [Note presence of Hallucinations or perceptual experiences in the absence of any corresponding external stimuli] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Note presence of Illusions – exaggeration, distortion, or misinterpretation of actual stimuli] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Categories: - [Auditory – these include, but are not limited to: Command hallucinations, Commentatory hallucinations] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Visual] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Tactile] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Olfactory] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Gustatory] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) THOUGHT FORM AND FLOW: - [Describe the amount and rate of thoughts] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [How connected thoughts are to one another] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Whether thoughts relate to a central idea] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) THOUGHT CONTENT: - [Describe the main topics discussed in the session] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Note the presence of any of the following: Delusions (paranoid, grandiose, persecutory, nihilistic, passivity phenomena (including: thought insertion, thought removal, thought broadcasting), ideas of reference)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Note Preoccupations/obsessions] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Note risk in any of the following areas: Suicide, Self-harm, Violence/aggression, Vulnerability, Absence without approval, Child safety] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) JUDGEMENT: - [Note if the person’s choices are adaptive or do they promote positive health outcomes and provide a rationale for answers then specify domains in which judgement is problematic in narrative paragraphs] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Note if the person utilises a logical, reality-based decision-making process when responding to situations and provide a rationale for answers then specify domains in which judgement is problematic in narrative paragraphs] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [If appropriate, consider using the following descriptors: Good/intact, Partial, Poor/impaired] INSIGHT: - [Note if the person is aware of their symptoms] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Note if they understand how the symptoms are impacting their functioning] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Note how the person explains their experience of symptoms and if it is based in reality, also consider what is commonly accepted within that person’s culture] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [If appropriate, consider using the following descriptors: Good/intact, Partial, Poor/impaired] COGNITION: - [Alertness] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Orientation (time, place, person)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Memory] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Concentration] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information include in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)