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/Somnolence

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Withdrawn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: __________________________