Mental Status Examination (MSE): Template, Example & Guide

The mental status examination (MSE) is the part of a clinical interview where the clinician records, in a fixed order, what they observe about a client's appearance, behaviour, speech, mood and affect, thinking, perception, cognition, insight and judgement. It is the psychiatric equivalent of the physical exam: a snapshot of the client's presentation at one point in time, written in terms another clinician can read and compare at the next visit 1, 2. This guide defines each MSE domain, gives a worked fictional example, and provides a template you can copy into your notes.

What is a mental status exam?

A mental status exam is a structured, descriptive record of observation. Most of it is gathered by watching and listening during the interview; a few parts (orientation, memory, attention) use brief direct questions or tasks 1, 2.

Three points define how it is used:

• It describes, it does not diagnose. MSE findings help distinguish mood disorders, thought disorders and cognitive impairment, and guide further testing or referral, but none is diagnostic on its own; each is interpreted in the context of the whole assessment 1, 2.
• It is a snapshot. The MSE records presentation during this encounter. History (what happened last week) belongs elsewhere in the note; the MSE is what you saw today.
• It is expected documentation. A Medicare contractor's coverage policy for psychiatric services (LCD L33252), for example, lists a mental status exam among the required record elements of a psychiatric diagnostic evaluation (CPT 90791) 3. In follow-up notes it usually appears in condensed form, in the Objective section of a SOAP note or the Data section of a DAP note.

The MSE domains at a glance

Domain names and order vary slightly between sources (some fold motor activity into behaviour, some list "sensorium and cognition"), but the content is consistent 1, 2.

Each domain, defined

Appearance

What a stranger could see: apparent versus stated age, build, dress and its fit for the setting and weather, grooming and hygiene, and visible features such as scars, tremor or signs of intoxication. Describe rather than judge: "clothing stained, hair unwashed" is more useful than "unkempt".

Behaviour and motor activity

How the client relates to the interview (cooperative, guarded, hostile, withdrawn, disinhibited), eye contact, and psychomotor activity: slowing (retardation) or agitation, restlessness, tics, tremor or other abnormal movements 2.

Speech

The form of speech, not its content: rate (slow, normal, rapid, pressured), volume, rhythm and prosody, quantity (poverty of speech, verbose), latency before answering, and articulation 2.

Mood and affect

These are recorded separately because they come from different sources: 2

• Mood is the sustained emotional state the client reports. Record it in their words where you can.
• Affect is the emotion the clinician observes. Describe its:
  • Range: full, constricted (reduced), blunted (markedly reduced) or flat (almost absent).
  • Stability: stable or labile (shifting rapidly).
  • Congruence: whether the affect fits the stated mood and the content being discussed. Laughing while describing a loss is incongruent.

Thought process

How ideas link together 2. Common descriptors:

Thought content

What the client is thinking about: dominant themes and preoccupations, obsessions, phobias, overvalued ideas, delusions (fixed false beliefs not shared by the client's culture), and suicidal and homicidal ideation 2. Always document risk content explicitly, including negatives ("denies SI, intent or plan"). A positive screen leads to a structured risk assessment such as the C-SSRS, not to a one-line MSE entry.

Perception

Perceptual disturbances: hallucinations (perception without a stimulus, by modality: auditory, visual, tactile, olfactory, gustatory), illusions (misperception of a real stimulus), and depersonalization or derealization. Note both what the client reports and what you observe, such as appearing to respond to internal stimuli 2.

Cognition

Level of consciousness (alert, drowsy, fluctuating), orientation (to person, place and time, written "oriented ×3"), attention and concentration, short- and long-term memory, and, where relevant, abstraction and fund of knowledge 1, 2. In most outpatient therapy notes a brief statement is enough. When cognition looks impaired, a standardized cognitive screen such as the MoCA or MMSE gives a scored, repeatable measure (see below).

Insight

How well the client understands that they have a problem, its likely causes and the need for treatment. Commonly rated good, fair, partial, poor or absent, with a short reason 2.

Judgement

The client's capacity to make sound decisions. It is better inferred from recent real choices (keeping a job, managing money, seeking help, risky behaviour) than from hypothetical questions 2.

Mental status exam example

A worked example for an outpatient intake. It is fictional: no real client, clinician or session.

Fictional example.

Mental Status Examination
Client: A.M., age 29, intake (90791), in person
Date: 2026-10-14

Appearance: Appears stated age. Casually dressed, clothing clean, hair
  unbrushed. No visible injuries.
Behaviour: Cooperative and engaged; eye contact intermittent, improved
  over the session. Mild psychomotor slowing. No abnormal movements.
Speech: Normal volume and articulation; slow rate with increased latency
  before answering. Decreased spontaneity.
Mood: "Heavy. Like I'm dragging myself through every day."
Affect: Constricted, dysphoric, stable; congruent with stated mood.
  Brief brightening when discussing her sister.
Thought process: Linear and goal-directed.
Thought content: Preoccupied with guilt about missed work. Endorses
  passive death wishes ("sometimes I wish I wouldn't wake up") in the past
  two weeks; denies active suicidal ideation, intent or plan; denies HI.
  No delusions elicited. (C-SSRS screener completed; see risk assessment.)
Perception: Denies auditory or visual hallucinations. Not observed to be
  responding to internal stimuli.
Cognition: Alert. Oriented to person, place, time and situation (×4).
  Attention intact (months of the year backward without error).
  Recall 3/3 immediately, 3/3 at five minutes.
Insight: Fair. Recognizes low mood as a problem; attributes it mainly
  to workload.
Judgement: Good. Self-referred, arranged time off work, has a support
  person at home.

Notice what the example does: it quotes the client's mood, separates the observed affect, states negatives as well as positives for risk, and gives evidence for the insight and judgement ratings. Scores from validated scales (for example a PHQ-9 of 17) sit beside the MSE in the note, not inside it; together they inform the clinician's diagnostic impression.

Mental status exam template

Copy this into your note and replace the brackets. Delete descriptors that do not apply rather than leaving them as a checklist.

Mental Status Examination
Client: [initials], [age], [session type]    Date: [YYYY-MM-DD]

Appearance: [apparent vs stated age; dress; grooming/hygiene; notable features]
Behaviour: [cooperative / guarded / agitated / withdrawn]; eye contact
  [good / intermittent / poor]; psychomotor [normal / slowed / agitated];
  abnormal movements [none / describe]
Speech: rate [normal / slow / rapid / pressured]; volume [ ]; rhythm and
  prosody [ ]; amount [ ]; latency [ ]
Mood: "[client's own words]"
Affect: range [full / constricted / blunted / flat]; [stable / labile];
  [congruent / incongruent] with mood
Thought process: [linear, goal-directed / circumstantial / tangential /
  flight of ideas / loose associations / blocking]
Thought content: [themes, preoccupations]; obsessions [ ]; delusions [ ];
  SI [denies / passive / active; intent; plan]; HI [denies / describe]
Perception: hallucinations [denies / modality and content]; responding to
  internal stimuli [no / yes]
Cognition: [alert / drowsy / fluctuating]; oriented ×[ ]; attention [ ];
  memory [ ]; screen used [none / MoCA ___ / MMSE ___]
Insight: [good / fair / partial / poor] because [ ]
Judgement: [good / fair / impaired] because [ ]

MSE vs MMSE: not the same test

The names are close and the two are often confused in search results and AI answers.

In short, the MMSE (or the MoCA) can be one tool inside the cognition domain of an MSE; it is not a substitute for the MSE. Reference pages: MMSE, MoCA.

Where the MSE fits in your documentation

• Intake / psychiatric diagnostic evaluation: a full MSE is an expected part of the record for CPT 90791 3. See the intake notes guide for the rest of the intake structure.
• Progress notes: a condensed MSE (often three to five lines, with any change from baseline) in the Objective or Data section. See the progress note formats compared side by side.
• Treatment plans: MSE findings and baseline scale scores together describe the starting point that measurable goals are written against. See the treatment plan guide.