Mental Status Examination (MSE)

The Mental Status Examination (MSE) Form provides a standardized framework for systematically documenting the key components of a psychiatric clinical assessment, serving as the mental health equivalent of the physical examination in general medicine. It captures observations and findings across all major MSE domains: general appearance and behavior, psychomotor activity, speech characteristics (rate, rhythm, volume, tone), mood (patient's subjective report), affect (clinician's objective observation of emotional expression), thought process (organization and flow of thinking), thought content (delusions, obsessions, suicidal/homicidal ideation), perceptual disturbances (hallucinations, illusions), cognitive function (orientation, attention, memory), insight into illness, and judgment and decision-making capacity.

The template is structured to guide clinicians through each domain sequentially while providing both standardized selection options for common findings and free-text fields for nuanced clinical descriptions. It includes contextual documentation fields for the patient's presenting complaint, current medications and substance use, and relevant psychiatric and medical history that inform MSE interpretation. A clinical impression section allows the examiner to synthesize findings into a coherent diagnostic formulation and document the differential diagnoses being considered.

Designed for psychiatric inpatient units, outpatient behavioral health clinics, emergency department psychiatric evaluations, forensic assessment settings, and primary care behavioral health integration programs, this form supports thorough, reproducible psychiatric documentation. It provides the structured clinical data needed for diagnostic formulation, treatment planning, competency and capacity evaluations, involuntary commitment proceedings, and communication between mental health providers across the continuum of care.