Mental status examination: template, structure and example

The mental status examination is a structured description of what the psychiatrist observes in the patient at the time of the interview, domain by domain. It covers appearance, behaviour, speech, mood and affect, thought content and form, perception, cognition, insight, judgement and risk.

This template is for psychiatrists and residents, in outpatient clinics, emergency departments or inpatient units. The examination is written at every initial assessment and repeated whenever the patient's state changes. It complements the history. The history tells what happened, the examination describes what can be seen now. That is what lets a colleague know the next day whether the patient is better or worse.

What the mental status examination is for

It is a dated clinical snapshot. Compared from one day to the next, it shows change under treatment. It supports important decisions, such as admission, discharge or involuntary care. It also ensures continuity between teams, provided it is written in terms everyone understands the same way.

When to use it

• At the first consultation or on admission.
• In the emergency department, for any psychiatric assessment.
• Whenever the patient's state changes significantly.
• Before discharge, leave or a change in the care setting.
• In a certificate or letter that must describe the current state.

The framework

In France, medical confidentiality applies to psychiatrists as to all doctors (article L1110-4 of the Public Health Code). The mental status examination is part of the patient's record, which has several consequences.

• The patient can access it. Article L1111-7 of the French Public Health Code gives everyone access to the formalised information about their health. It is released no earlier than 48 hours and no later than 8 days after the request, extended to 2 months for information more than 5 years old.
• There is an exception in psychiatry. For a person receiving involuntary care, access may, exceptionally and where risks are particularly serious, require the presence of a doctor chosen by the requester. If the person refuses, the departmental psychiatric care commission can be asked to decide.
• Information about third parties. What was gathered from third parties who are not involved in care, or that concerns those third parties, cannot be disclosed.

In practice, write each section as if the patient will read it. A precise, neutral description such as "says he hears his neighbour's voice criticising him" is more useful and fairer than a judgement.

The structure, section by section

1. Appearance

Apparent age, clothing, hygiene, visible physical signs (weight loss, injuries, scars). The MSD Manual notes that appearance can reveal poor self-care, substance use or self-harm.

2. Behaviour and rapport

Attitude during the interview, eye contact, cooperation, agitation or slowing, abnormal movements. Quality of rapport, from warm to guarded.

3. Speech

Rate, volume, spontaneity, sentence structure. Very fast speech that is hard to interrupt, or slow and sparse speech, guides the assessment.

4. Mood and affect

Mood is what the patient describes, ideally quoted in their words. Affect is what you observe, its intensity, range and fit with what is being said.

5. Thought form

How ideas connect. Clear and organised thinking, or fast, slow, tangential thinking, with breaks or off-target answers.

6. Thought content

Main concerns, ideas of guilt or ruin, obsessions, delusions (theme, degree of conviction), thoughts of death, suicide or violence.

7. Perception

Hallucinations (auditory, visual or other), with their content and the patient's behaviour (seems to be attending to something, answers under their breath). Note whether they recognise them as abnormal.

8. Cognition

Alertness, orientation to time and place, attention, memory. State the method, such as a brief test or simple observation.

9. Insight

The patient's awareness of having a disorder and needing care. Describe it in their own words rather than with a rating.

10. Judgement

The ability to make decisions suited to their situation, assessed from concrete examples.

11. Risk assessment

Suicide risk (thoughts, plan, means, history), risk to others, vulnerability (self-neglect, exposure to abuse). The French consensus conference on the suicidal crisis encourages asking directly about suicidal thoughts.

12. Summary

One to three sentences summing up the current state and the action taken. In an emergency, this is often the only part that gets read.

Filled-in example

Fictional patient. All details are invented.

Context. Mr B., 27, seen in the emergency department, brought by his sister because of a change in behaviour over three weeks.

Appearance. Looks his age. Unkempt, clothes worn for several days according to his sister. Visible weight loss. No apparent injury.

Behaviour and rapport. Sits on the edge of the chair, looks towards the door several times. Cooperative but guarded. No agitation.

Speech. Normal rate, low volume. Brief answers, sometimes after a long delay.

Mood and affect. Says he feels "on guard". Restricted, anxious affect.

Thought form. Broadly coherent, with some off-target answers when the interview turns to his neighbours.

Thought content. Convinced that his neighbours are watching him through hidden cameras in his flat and are "planning something". Strong conviction, no doubt expressed. No ideas of guilt. Asked directly, denies any suicidal thoughts. Says he wants "to defend himself if they come for him", with no specific plan or target.

Perception. Reports hearing voices at night commenting on his actions. Appears to be attending to something twice during the interview.

Cognition. Alert, oriented to time and place. Fluctuating attention. Memory not assessed in detail.

Insight. "I'm not ill, they're the problem." Agrees to stay in the emergency department "to get some sleep".

Judgement. Has stopped going to work and no longer goes out shopping for fear of being followed.

Risk. No suicidal thoughts expressed. Risk to others to monitor given the defensive statements, with no plan and no reported access to a weapon. Vulnerability linked to weight loss and isolation.

Summary. Recent onset of persecutory ideas with auditory hallucinations, without insight, in a patient with no known psychiatric history. Physical work-up requested. Admission offered and discussed with the patient and his sister.

Common mistakes

• Copying the history into the examination instead of describing the current state.
• Using labels without examples, such as "delusional" or "disorganised", without saying what was observed.
• Confusing reported mood with observed affect.
• Leaving out important negatives, for example not writing that the patient denies suicidal thoughts.
• Writing "oriented" without saying to what or how it was checked.
• Forgetting to date and time the examination, even though the state can change within a day.
• Using pejorative terms the patient may read.
• Ending without a summary or the action taken.

Save time with Delta

Delta is the clinical assistant for mental health and allied health professionals. During the consultation, Delta transcribes what is said. You can also dictate your observations afterwards, for example your mental status examination section by section, or add written notes. Delta then generates the report (short summary, detailed summary, topics for the next consultation), taking into account your profession, and updates the patient record with a summary of care and the goals being tracked. Delta also drafts letters suited to your profession. Data is hosted in France with an HDS-certified provider, the patient's name and identifying details are pseudonymised before the AI, no audio file is kept and data is never used to train a model. Learn more about Delta.

Read also

• Crisis session note and suicide risk assessment
• First session intake, template and structure
• ChatGPT for clinical notes, what to know
• All clinical document templates

Sources

• MSD Manual, professional edition, Initial psychiatric assessment (in French)
• Service-public.fr, access to medical records (in French)
• AP-HP legal affairs department, access to medical records, article L1111-7 (in French)
• HAS (ANAES), The suicidal crisis: recognition and care, consensus conference, 2000 (in French)