Mental Status Exam Template and Examples
A mental status exam (MSE) template covering appearance, behavior, speech, mood, affect, thought process and content, perception, cognition, insight and judgment, with descriptor options, two example write-ups and a free builder.
The MentalNote web app drafts treatment plans, intake assessments and progress notes from a recorded session, for you to review and edit. Free plan: 5 web-app scribe sessions a month, no credit card.
Illustrative and educational. The examples below describe fictional clients. The MSE records what you observe at one point in time; it does not make a diagnosis. Follow your training, scope of practice and agency requirements.
The 10 parts of a mental status exam
| Domain | What you note | Example wording |
|---|---|---|
| Appearance | Grooming, dress, hygiene, apparent age, notable features | Casually dressed, appropriately groomed, appears stated age. |
| Behavior | Eye contact, cooperation, psychomotor activity | Cooperative, good eye contact, mildly restless. |
| Speech | Rate, volume, rhythm, quantity | Normal rate and volume; soft at times. |
| Mood | The client's own description, ideally quoted | "Stressed and tired." |
| Affect | What you observe: range, intensity, stability, congruence with mood | Anxious, restricted range, congruent with stated mood. |
| Thought process | How thoughts are organized and connected | Linear and goal-directed. |
| Thought content | Themes, preoccupations, delusions, suicidal or homicidal ideation | Preoccupied with work deadlines; denies suicidal and homicidal ideation. |
| Perception | Hallucinations or other perceptual disturbances | No perceptual disturbances reported or observed. |
| Cognition | Alertness, orientation, attention, memory | Alert and oriented to person, place, time and situation; attention intact. |
| Insight and judgment | Understanding of the problem; quality of decisions | Insight fair; judgment good. |
Glossary: mood, affect, congruent affect, blunted affect, thought process, tangential speech, circumstantial speech, orientation, insight and judgment.
Free MSE builder
Tick what you observed and the builder writes a draft MSE paragraph in standard order. Domains you leave blank are marked "not documented" rather than filled with normal findings. Edit the draft before you use it.
Mental status exam examples
Two fictional write-ups: a brief checklist style and a narrative paragraph. Either is acceptable; use the style your setting expects.
Example 1: brief format, outpatient follow-up (fictional)
Appearance: Casually dressed, appropriately groomed, appears stated age. Behavior: Calm, cooperative, good eye contact. No psychomotor abnormalities. Speech: Normal rate, volume and rhythm. Mood: "Pretty good this week." Affect: Euthymic, full range, congruent with stated mood. Thought process: Linear and goal-directed. Thought content: No delusions elicited. Denies suicidal and homicidal ideation. Perception: No perceptual disturbances reported or observed. Cognition: Alert and oriented x4. Attention and recent memory grossly intact. Insight: Good. Judgment: Good.
Example 2: narrative format, intake for low mood (fictional)
Client presented as an adult who appeared stated age, casually dressed with fair grooming. They were cooperative but made limited eye contact and showed mild psychomotor slowing. Speech was soft and slow with increased latency of response. Client described their mood as "empty." Affect was dysphoric and restricted, congruent with stated mood; client was tearful when discussing work. Thought process was linear and goal-directed. Thought content focused on feelings of worthlessness about work performance; no delusions were elicited. Client reported passive thoughts of not wanting to wake up, without intent or plan; a full suicide risk assessment and safety plan are documented separately. No perceptual disturbances were reported or observed. Client was alert and oriented to person, place, time and situation; attention was mildly reduced on serial sevens. Insight was fair, as client recognizes a change in mood but attributes it to personal failure. Judgment was fair, as client sought treatment.
Tips for writing the MSE
- Separate mood from affect. Mood is what the client reports; affect is what you observe. Quote the client's mood when you can.
- Describe, don't label. "Spoke quickly and was hard to interrupt" tells the next reader more than "pressured" alone.
- Document risk explicitly. Record suicidal and homicidal ideation as asked and answered, and put the full risk assessment in its own section.
- Document only what you assessed. If you did not test memory, don't write "memory intact".
- Repeat it over time. An MSE at intake and at later sessions shows change that supports the treatment plan.
For more wording, see words to describe affect, how to describe mood and clinical terminology for progress notes.
Where the MSE fits
The MSE is part of an intake or biopsychosocial assessment, and a short MSE often sits in the Objective section of a SOAP note or the Data section of a DAP note. Findings feed the treatment plan.
Frequently asked questions
What are the components of a mental status exam?
Most MSE formats cover appearance, behavior and psychomotor activity, speech, mood, affect, thought process, thought content (including suicidal and homicidal ideation), perception, cognition (alertness, orientation, attention, memory), insight and judgment.
What is the difference between mood and affect?
Mood is the client's own description of how they feel, ideally quoted. Affect is the emotional expression you observe, described by range, intensity, stability and whether it is congruent with the stated mood.
How do you write a normal mental status exam?
Describe each domain you assessed, for example: appropriately groomed, cooperative, normal speech, euthymic and full-range affect, linear thought process, no delusions, denies suicidal and homicidal ideation, no perceptual disturbances, alert and oriented, good insight and judgment. Only record what you actually assessed.
Does the MSE builder save what I select?
No. The builder runs in your browser and nothing is sent or saved. Use it for de-identified drafts. For notes about real clients, use MentalNote, which is HIPAA-compliant, with a BAA included on every plan.
Is the MSE a diagnosis?
No. The MSE describes a client's presentation at one point in time. It is one input, alongside history and other assessment, to clinical formulation and diagnosis.
Let MentalNote draft the note around your MSE
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