MENTAL STATUS EXAMINATION (MSE)

Gathering the correct information about the client’s mental status is essential to the development of an
appropriate plan of care. MSE is a description of all areas of the client’s mental functioning as observed
by the examiner at the moment.
Date:
Name:
Gender:
Age: (How old are you? When were you born?)
I. PREEXAMINATION Mark Description/Verbatim Quotes
A. General Appearance
1. Grooming and dress
a. Note unusual modes of dress
b. Evidence of soiled clothing
c. Neat, unkempt?
d. Use of make up?

2. Hygiene
a. Note evidence of body or breath odor
b. Condition of skin, fingernails
c. Disheveled
d. untidy

3. Height and weight

a. Perform accurate measurements

4. Level of Eye contact

a. Intermittent
b. Occasional and fleeting
c. Sustained and intense
d. No eye contact?

5. hair and color texture

a. Is hair clean and healthy looking
b. Greasy, matted , tangled?

6. Evidence of scars, tattoos or other

distinguishing skin marks
a. Note any evidence of swelling or bruises
b. Birth marks
c. Rashes
7. Evaluation of client’s appearance
compared with chronological age ,
deterioration of appearance, client needs
to be reminded
B. General Mobility
1. Posture
a. Note if standing upright, rigid, slumped
over
b. Note for:
Catatonia
Catatonic Stupor
Catatonic rigidity
Catatonic posturing
Waxy flexibility
Catalepsy
Cataplexy

2. Gait patterns
a. Any evidence of limping
b. Limitation of range of motion
C. Ataxia
d. Shuffling

C. Motor Activity
Note for:
Normoactivity
Hyperactivity
Psychomotor retardation
Agitation
Tremors (hands, legs, continuous, at
specific time
Tics
Jerky or spastic movements
Stereotypical Movements
Mannerisms and Gestures
Aggressiveness
Echopraxia
Bradykinesia
Pacing and Rocking
Somnambulism
Anchoring
Anergia
Anhedonia
Regression
Compulsions
D. Behavior/ Nurse patient Interaction
Cooperative
Cooperative (initially, all though out)
Uninterested/Apathetic
Friendly
Embarrassed
Seductive
Impulsive
Negativistic
Indifferent
Angry/hostile
Evasive
Withdrawn
Warm
Distant
Guarded/Suspicious
Dependent
Distracted
II. STREAM OF TALK
A. Character
Note for:
Slowness or rapidity
Intonation
Volume
Stuttering, hoarseness, slurring
Spontaneous
Blocking
Deliberate
Pressured
Aphasia

B. Organization of Talk/Form of Thought

Relevant
Irrelevant
Incorrect
Flight of Ideas
Loose association
Circumstantiality
Tangentiality
Neologism
Concrete Thinking
Clang Association
Word Salad
Perseveration
Echolalia
Mutism
Bradylalia
Poverty of Speech
Glossolalia
Coprolalia
Verbigeration
Condensation
III. EMOTIONAL STATE AND
REACTIONS
A. Mood
Euthymic
Depression/despairing
Euphoria
Elation
Fearful
Irritable
Anxious
Guilty
Labile

B. Affect
Congruence with mood
Constricted/ Blunted
Flat
Appropriate
Inappropriate

IV. THOUGHT CONTROL/PROCESSES

Content of Thought
A. Delusions
Persecutory
Grandiose
Reference/ideas of reference
Control/Influence (Thought Broadcasting,
Thought Withdrawal, Thought Insertion)
Somatic
Nihilistic
Erotomanic
Jealous
Religious

B. Suicidal Thought/ideation
Attempt
Threat
Gestures

C. Obsessions
D. Magical Thinking
E. Phobia
F. Poverty of Content

Perceptual Disturbances
1. Hallucinations
Hypnagogic
Hypnopompic
Visual
Auditory
Tactile
Olfactory
Gustatory
Trailing Phenomenon
Micropsia (lilliputian)
Marcopsia

2. Illusions
Visual
Auditory
Tactile
Olfactory
Gustatory
3. Depersonalization
Derealization
4. Preoccupation
Ruminations
5. Déjà vu
Jamais vu

Impulse Control
Ability to control impulses
a. Aggression
b. Hostility
c. Fear
d. Guilt
e. Affection
f. Sexual feelings
V. NEUROVEGETATIVE DYSFUNCTIONS
A. Sleep
Normal
Hypersomnia
MNA
EMA
DFA
Interrupted

B. Appetite
Poor/fair/good
Polyphagia
Voracious
Pica
Binge eating
Coprophagia
 C. Diurnal Variation
D. Weight
E. Libido
VI. GENERAL SENSORIUM AND
INTELLECTUAL STATUS
Describe impaired or unimpaired
A. Orientation(place, time , person,
situation)
B. Memory
Recent
Remote
Immediate
Confabulation
Agnosia
Apraxia
Amnesia

C. Attention Span
D. General Information
E. Abstract Thinking Ability
F. Judgment /Reasoning
1. Ability to solve problems and make
decisions, make plans for the future

VII. INSIGHT
Describe impaired or unimpaired
Knowledge about Self, limitations
Awareness of illness
Ask: Do you think you have a problem?
Do you think you need treatment
Adaptive/Maladaptive use of coping
mechanism
VIII. SUMMARY OF MSE
A. Disturbances in:
( ) Presentation
( ) Stream of Talk
( )Emotional State and Reactions
( ) Thought Processes
( ) Neurovegetative Dysfunctions
( ) Sensorium and Intellectual Status
( ) Insight
B. Diagnostic Category (DSM IV :
Diagnostic and Statistical Manual of
Mental Disorders

Assessed by: __________________________