Mental Status Exam (MSE)

Finished note

Example — generated by Notat from a sample visit

Presenting concern:
Reports increased anxiety and disrupted sleep during a period of work-related stress. Denies thoughts of self-harm.

Assessment:
Anxiety symptoms affecting sleep and daily functioning; no immediate safety concern disclosed.

Plan:
Discussed coping strategies, sleep routine, and follow-up. Patient knows how to seek urgent support if safety concerns arise.

Clinical documentation:
Relevant symptoms, meaningful negatives, assessment, and follow-up advice were captured from the sample visit and organised into the selected template.

FactsContext™

Template

Mental Status Examine (MSE)

Date/Time: [Date and Time]
Patient Identifier: [Name]

Appearance:
(hyphenated list)
- [General build, posture, and bearing]
- [Clothing, grooming, and hygiene]
- [Notable features: tattoos, piercings, scars]

Behavior:
(hyphenated list)
- [Level of cooperation or guardedness]
- [Eye contact: appropriate, poor, intense]
- [Psychomotor activity: agitated, slowed, normal]

Speech:
(hyphenated list)
- [Rate: fast, slow, normal]
- [Volume: loud, soft, normal]
- [Articulation, coherence, latency]

Mood:
(hyphenated list)
- Subjective: “[Patient’s own description of mood]”
- Objective: [Euthymic, depressed, anxious, irritable, etc.]

Affect:
(hyphenated list)
- [Range: full, restricted, blunted, flat]
- [Congruence with stated mood]
- [Stability: labile, stable]

Thought process:
(hyphenated list)
- [Organization: linear, goal-directed, tangential, circumstantial]
- [Flight of ideas, loosening of associations, perseveration]

Thought content:
(hyphenated list)
- [Suicidal ideation: present/absent, with or without plan]
- [Homicidal ideation: present/absent, target if any]
- [Delusions, obsessions, overvalued ideas]
- [Preoccupations, phobias]

Perception:
(hyphenated list)
- [Hallucinations: auditory, visual, tactile, olfactory]
- [Illusions or depersonalization/derealization]

Cognition:
(hyphenated list)
- Orientation: person, place, time, situation
- Attention/Concentration: [e.g., serial sevens, digit span]
- Memory:
- Immediate: [better/worse than expected]
- Recent: [able/unable to recall events of the past few days]
- Remote: [able/unable to recall past events]
- Fund of knowledge: [general information and vocabulary]
- Abstract thinking: [proverb interpretation or similarities]

Insight:
(hyphenated list)
- [Good, fair, poor]
- [Awareness of illness and need for treatment]

Judgment:
(hyphenated list)
- [Appropriate, impaired]
- [Examples of decision-making capacity]

Risk Assessment:
(hyphenated list)
- Suicidal risk: [ideation, intent, plan, means]
- Homicidal risk: [ideation, intent, plan, means]
- Self-harm behaviors or past attempts
- Risk to others or vulnerability factors

Formulation:
(in paragraphs)
[Integrate presenting symptoms, diagnostic impressions, risk factors, and relevant psychosocial context into a concise clinical summary.]

Plan:
(Use medical terminology if appropriate. Do not fabricate.)
- [Immediate safety measures or hospitalization if indicated]
- [Medication recommendations and dosing]
- [Psychotherapy referrals or supportive interventions]
- [Laboratory or imaging studies]
- [Follow-up appointment: timeframe and setting]