Mental Status Exam Example
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Looking for a mental status exam example to use when evaluating a client’s presentation and mental health? This article provides mental status exam examples, a mental status exam template, and information on how to conduct a mental status exam (MSE).
Whether you’re a therapist, social worker, or provide crisis support, you’ll be involved in evaluating a client’s mental health and presentation—often by conducting an MSE. It can be challenging to remember all the components and terminology, especially if you’re a recently graduated clinician or new to providing mental health care.
Along with the mental status exam template, this article includes mental status examples, complete with mental status questions, a mental status examination sample report PDF, and more.
Customize the mental status exam template from this article to fit your client’s needs, or download the mental status examination PDF and save it to your electronic health record (EHR) for repeated use.
What is a mental status exam (MSE)?
A mental status exam assesses cognitive and behavioral functioning during an encounter with a client.
Depending on the type of clinician performing an MSE, they may test multiple cognitive functions and/or use different clinical measures. We’ve provided some mental status exam examples below for various situations.
Typically, therapists use an MSE when completing a biopsychosocial assessment. The exam can also be readministered at various stages throughout the client’s treatment.
In some instances, like when a therapist bills insurance, they may be required to complete a brief MSE within their electronic health record for each visit.
Mental status exams are helpful because they provide valuable insights into a client’s mental health or current state and can be used to document a diagnosis, devise a treatment plan, and monitor client progress.
Core components of a mental status exam template
Appearance and general behavior
This section describes the individual’s physical appearance (grooming, attire, height, weight, age) and behavior (demeanor and mannerisms, levels of engagement/lack of cooperation, eye contact, and speech).
Mood and affect
In this section, clinicians observe the client’s emotional state and how they express themselves. For example, the clinician may note an anxious mood, but the client’s facial expression is incongruent, and they may present a different emotional state.
Cognition
This section measures the person’s awareness and executive function.
Cognition is assessed in several areas:
- Thought process and content: This category observes the client’s responses and thoughts. For example, are they able to respond to questions with trust, or do they appear suspicious? Is their thought process organized? Does it demonstrate logic and reasoning?
- Delusions: This measure assesses if the client’s response is unremarkable, or if they show signs of aggravation, misinterpretation, or obsession.
- Perception: This measures how the client responds to stimuli. Do they observe the same things as others in the room or do they have a false auditory or visual perception?
It’s important for a clinician to consider all relevant information when conducting an assessment, including noting risk factors, protective factors, and forces and barriers that may be impacting their access to resources.
Risk factors
- History of involuntary hospitalizations
- History of trauma
- No current mental health support, with a history of mental health concerns requiring support (e.g., schizoaffective disorder or other psychotic disorders)
- The client has poor insight into their situation
- Unhoused, with limited social and financial resources
- Strained familial relationships
Protective factors
- Can advocate for their own needs
- Close relationships with family, who are a source of support
- Housing with adequate resources for sustenance
- Gainful employment
- Social support
- Established health care, including mental health care
Racial and cultural factors to consider
It’s also important to consider other sociological and socioeconomic factors during a mental status examination.
For example, people of color face numerous barriers to healthcare.
Black Americans typically have less access to quality healthcare due to therapy deserts in communities of color—resulting in only one in three Black adults who need mental healthcare receiving it.
A person of color is also more likely to experience systemic and structural racism, trauma, and oppression, which has a negative effect on mental health. Racism can also be present in health care. Provider bias and inequality of care contributes to stigma, a lack of cultural competency, and underdiagnosis or misdiagnosis of people of color.
For example, a Black adult male is four times more likely to be diagnosed with schizophrenia than a white male. Indicating providers overemphasize psychotic symptoms in Black men, while mood symptoms of depression, for example, are often overlooked.
Young people of color are also disproportionately affected by racial biases in healthcare. According to Mental Health America (MHA), BIPOC youth with mental or behavioral issues are often unfairly penalized and imprisoned, instead of receiving mental health services. Approximately 50-75% of youth in juvenile detention meet a diagnosis for a mental health condition.
Yet in 2020, roughly 10% of Black adults in the United States did not have any form of health insurance—making it even more difficult to find and afford care and treatment.
While many risk factors may be present for an individual in a mental status exam, it's crucial to consider them in context of forces of oppression that may also be contributing to the person’s circumstances.
For example, given the prevalence of misdiagnosis in people of color, they may be less open and authentic with a white clinician and even feel unsafe.
As clinicians, we can and should try to provide them with accessible and culturally competent resources within their community.
Mental status exam examples
Here are two examples of scenarios in which a clinician might document a mental status exam:
Situation
An individual seeking therapy for depression.
Mental status exam example
Client is a 40-year-old white male, married, and seeking treatment for depression. They presented as well-groomed, clean shaven, maintained eye contact, and engaged during the assessment.
In their intake paperwork and during the intake session, they reported feeling low, oftentimes crying, which was congruent with a depressed affect. The client believed the reason for their depression was due to the recent loss of their mother—showing insight, cohesion, and logical thought process and content. During the assessment, they appeared oriented, with unremarkable perception, and no signs of delusions.
Risk assessment: The clinician administered an Ages and Stages Questionnaire (ASQ) screening as part of the intake paperwork and repeated this during the assessment. The client did not demonstrate suicidal ideation.
Protective factors: The client reported to be in a loving marriage with a supportive partner, and having an active social life. While they are clearly impacted by their grief, they also mentioned being part of a close family, who are supporting one another in the grieving process. The client remains engaged in work and has several hobbies.
Situation
Crisis response call to a female who appeared to be experiencing hallucinations.
Mental status exam example
The crisis team responded to a police call regarding a white 30-year-old female they thought was experiencing psychosis. On arrival, the crisis team was greeted by the building manager where the client resides, and the crisis team observed the client walking in the yard outside their house.
The building manager reported that the client broke into the main office last night, believing the staff had stolen some of their personal possessions. The client’s appearance was disheveled, they were wearing inappropriate clothing (their pajamas), and they appeared gaunt and below average weight for their age and height.
Their mood was anxious and labile, with minimal eye contact. They appeared to be acutely distracted by external stimuli, including auditory and visual hallucinations to the extent that they were unable to engage in the assessment.
The crisis team also observed the client mumbling to themselves, but with pressured speech, and they showed restless psychomotor activity, as they were unable to stand still. Taken together, the crisis team concluded the client’s cognition showed poor perception, impulse control, and judgment.
Risk factors: The building manager reported the client lives alone.
Protective factors: The building manager also mentioned that they contacted the client’s emergency contact, their sister, whom they have a close relationship with and is a solid source of support. The manager mentioned that their sister is on the way and had experience supporting their sister through these “episodes.”
Mental status exam questions to ask
Below are examples of questions to ask clients during each section of the exam:
Mood
- How would you describe your mood?
- What is your mood like generally?
- For example, would you describe yourself as happy, sad, angry, depressed, very happy, or frightened?
- Are these moods you feel all the time, or have you noticed a change? If so, why do you think that is?
Thought processes and content
- Do you ever see things that other people don’t see?
- Do you ever hear things others don’t?
- I noticed you looking to your right a lot. What do you see?
- Can you describe what you’re hearing at the moment?
- Do you ever feel suspicious of other people?
Cognition
- What is today’s date?
- Who is the president of the United States?
- Do you know what time it is right now?
- What is your name and address?
- Repeat the following nine words: It’s a sunny day and the sky is blue.
Suicidal ideation
According to the ASQ Suicide Risk Screening Tool, questions to ask include:
- In the past few weeks, have you wished you were dead?
- In the past few weeks, have you felt that you or your family would be better off if you were dead?
- In the past week, have you been having thoughts of killing yourself?
- Have you ever tried to kill yourself?
If the client answers yes to any of these, follow up by asking:
- Are you having thoughts of killing yourself right now?
If the client answers yes to the follow-up question, this is an acute positive screen, and they should be evaluated for safety immediately. If they answer no to all of the preliminary questions, or to the last question, the clinician should move on to complete the ASQ assessment. There are also versions of this assessment for adults in inpatient and outpatient settings, along with a combined Patient Health Questionnaire (PHQ-9) and ASQ tool.
How and when to use the mental status exam template
The mental status exam template can be used in various situations, such as:
- Intake assessment
- Biopsychosocial assessment
- Crisis situations
- Primary care settings
- Emergency departments
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