EXAMPLE---MENTAL STATUS EXAM NARRATIVE

Mr. Jones is a 35 year old male who appears older than his stated age. He is separated from his

spouse.

His dress was disheveled with dirty t-shirt, ripped jeans; and shoes with holes in them. His

grooming and hygiene were inadequate. He was resistant to the interview. His posture was

slumped; mood was angry; affect was flat; rate of speech was slowed; tone was soft. His thought

processes were incoherent. He did not demonstrate appropriate insight. His thought content was

delusional and he demonstrated psychotic symptoms. He did not deny auditory hallucinations.

He denied obsessions and compulsions and he denied phobias. He was not oriented to time,

place, and person. His memory was impaired; intelligence was estimated to be above average;

judgment and impulse control were inadequate. He denied suicidal and homicidal ideations.