Free Mental Status Exam Template in Word, PDF, and Google Docs

A Mental Status Exam (MSE) is a clinical assessment used to document a patient’s observable behavior, cognitive function, and reported mood during a psychiatric or psychological evaluation. It is commonly used in both inpatient and outpatient settings to record baseline mental status and monitor changes over time. You can customize this mental status exam template in Word and Google Docs.

How to Use This Mental Status Exam Template

This template is designed for clinicians conducting face-to-face or telehealth evaluations. Each section covers a core domain of the mental status exam. Selections can be made using checkboxes, with space for clinical notes.

• Patient Information. Record identifying details including the patient’s name, date of birth, gender, the assessor’s name, and date of assessment. Use the AM/PM checkboxes to indicate the session time. Accurate timestamping is essential for clinical records and follow-ups.
• Appearance. Select terms based on observed grooming, attire, and hygiene. This field helps in identifying disorganization, neglect, or unusual presentation patterns. Descriptions in the notes should avoid subjective interpretation and focus on visible signs.
• Behavior. Choose all applicable options based on motor activity, eye contact, and interpersonal engagement. Note that behaviors like psychomotor slowing or hyperactivity may signal medication side effects or acute distress. Use this section to document both spontaneous behavior and responses to engagement.
• Consciousness. Mark the current level of alertness. If fluctuations are noted during the session, this should be explained in the notes. For patients under sedation or post-seizure, repeated evaluations may be needed.
• Orientation. Tick based on patient’s correct identification of time, place, person, and situation. Consider administering a brief orientation test if the patient shows confusion or is in an unfamiliar environment.
• Speech. Evaluate clarity, latency, volume, and fluency. Disorganized speech patterns such as incoherence or pressure may support diagnostic impressions. Use the notes to clarify examples, such as neologisms or repeated phrases.
• Mood (Subjective). Document the patient’s self-described emotional state in their own words. Avoid paraphrasing. This entry should reflect exactly what the patient reports, as it provides context for overall affect and tone.
• Affect (Objective). Assess the observable emotional range and whether it aligns with the stated mood. Note any shifts during the session. For patients with mood instability or flat affect, provide concrete examples in the observation field.
• Thought Process. Select based on how ideas are connected and expressed. Disruptions like tangential thinking or blocking should be documented with clinical examples. This field is crucial when evaluating thought disorganization or psychotic symptoms.
• Thought Content. Identify abnormal beliefs, obsessions, or risks. If suicidal or homicidal thoughts are present, assess for frequency, intensity, and whether a plan exists. This section may also reflect delusions, guilt, or grandiosity and should be documented with specific phrases or behaviors.
• Perception. Note hallucinations or distortions. Include modality (auditory, visual, tactile, etc.), content, and insight. If the patient reports perceptual changes but denies hallucinations, specify the distinction in the notes.
• Cognition. Mark general function and assess memory domains if relevant. For formal cognitive assessments like MMSE or MoCA, include the score and date. When documenting impairment, provide specific areas (e.g., delayed recall, disorientation).
• Insight. Evaluate the patient’s awareness of their condition, treatment need, or behavioral consequences. Insight may shift between sessions and should be compared to prior assessments if applicable.
• Judgment. Use clinical examples to determine soundness of decision-making. Consider recent behavior, responses to hypothetical questions, or ability to assess risk. This is especially relevant for discharge planning or independent living assessments.
• Risk Assessment. Select based on current or recent risk indicators. Include the presence of a plan, means, prior history, and any protective factors. Notes should reflect the clinician’s clinical reasoning for risk level assigned.
• Functioning / ADLs. Assess the patient’s ability to manage tasks such as bathing, dressing, and meal preparation. Use this section to evaluate functional decline or support needs for daily routines.
• Substance Use. Record active use or recent history. Include frequency, last use, and whether the substance use is relevant to current symptoms. “None” should only be selected after confirming absence of current or historical use.
• Additional Notes. Document any collateral input (e.g., from family, caseworkers), clinical impressions, or context not covered in prior sections. This may also include legal issues, diagnostic hypotheses, or treatment considerations.

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