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Psychiatric Specialist
10-15 minutes

Psychiatric Status Evaluation (PSE)

The Mental State Examination (MSE) template by s10.ai is an essential resource for psychiatrists, psychologists, and mental health nurses, crafted to facilitate a comprehensive assessment of a patient's mental status. This template meticulously covers critical areas including appearance, behavior, speech, mood, affect, thoughts, perceptions, cognition, insight, and judgment. It empowers clinicians to systematically evaluate and document mental health, ensuring thorough and consistent examinations. Ideal for generating detailed psychiatric SOAP notes and mental health progress notes, this template is a vital tool for mental health professionals seeking to enhance their clinical documentation and patient care. Explore s10.ai's MSE template to streamline your mental health assessments today.

2,032 uses
4.3/5.0
D
Dr. Emily Chen
Template Structure

Organized sections for comprehensive clinical documentation

Mental State Assessment:
- Appearance: [Detail the patient's attire, grooming, and any significant physical traits (include only if applicable)]
- Behaviour: [Outline the patient's activity level, engagement with their environment, and any distinct or noteworthy behaviors (include only if applicable)]
- Speech: [Observe the pace, loudness, clarity, and coherence of the patient's speech (include only if applicable)]
- Mood: [Document the patient's self-reported emotional state, using their own words if possible (include only if applicable)]
- Affect: [Describe the range and suitability of the patient's emotional response during the assessment, noting any inconsistencies with the stated mood (include only if applicable)]
- Thoughts: [Evaluate the patient's thought process and content, noting any distortions, delusions, or fixations (include only if applicable)]
- Perceptions: [Record any reported hallucinations or sensory misinterpretations, specifying type and effect on the patient (include only if applicable)]
- Cognition: [Detail the patient's memory, orientation to time/place/person, concentration, and understanding (include only if applicable)]
- Insight: [Describe the patient's awareness of their own condition and symptoms, noting any lack of insight or denial (include only if applicable)]
- Judgment: [Describe the patient's decision-making capacity and understanding of the consequences of their actions (include only if applicable)]
(Never create your own patient details, assessment, diagnosis, interventions, evaluation, and plan - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant section blank.)
Sample Clinical Note

Example of completed documentation using this template

Mental Status Examination:
- Appearance: The individual is a 45-year-old male, dressed casually, with good personal hygiene and no distinguishing physical features.
- Behaviour: The individual is cooperative and maintains appropriate eye contact. He is calm and engages suitably with his environment.
- Speech: The individual's speech is normal in rate, volume, and clarity. His speech is coherent and pertinent to the discussion.
- Mood: The individual reports feeling 'anxious and stressed.'
- Affect: The individual's affect aligns with his reported mood, displaying a limited range of emotions.
- Thoughts: The individual's thought process is logical and goal-directed. There are no indications of delusions or fixations.
- Perceptions: The individual denies experiencing any hallucinations or sensory distortions.
- Cognition: The individual is oriented to time, place, and person. His memory and concentration seem intact.
- Insight: The individual shows good insight into his condition, recognizing his symptoms and the necessity for treatment.
- Judgment: The individual's judgment is intact, and he comprehends the consequences of his actions.
Clinical Benefits

Key advantages of using this template in clinical practice

  • The Mental Status Examination template is an essential tool for clinicians seeking a comprehensive assessment of a patient's psychological and cognitive functioning. This template guides healthcare professionals through a detailed evaluation of key areas such as appearance, behavior, speech, mood, affect, thoughts, perceptions, cognition, insight, and judgment. By utilizing this structured approach, clinicians can accurately document and analyze a patient's mental health status, facilitating effective diagnosis and treatment planning. The template's focus on high-search healthcare keywords ensures that it meets the needs of modern clinical practice, making it an invaluable resource for mental health assessments. Adopt this template to enhance your clinical documentation and improve patient care outcomes.
Frequently Asked Questions

Common questions about this template and its usage

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