A mental status exam records what you observed during the encounter, not what the patient reported about the past. That single distinction is what separates a usable exam from a history repeated twice. Below are the nine components, a template, and three complete exams for different presentations.
The nine components
| Component | What you record |
|---|---|
| Appearance | Grooming, hygiene, dress, apparent age against stated age, any physical findings you can see |
| Behavior | Eye contact, psychomotor activity, cooperation, unusual movements, attitude toward the interview |
| Speech | Rate, volume, rhythm, latency, spontaneity, any dysarthria or pressured quality |
| Mood | What the patient says they feel, quoted in their own words where possible |
| Affect | What you observe: range, intensity, reactivity, congruence with the stated mood |
| Thought process | The form of thinking: linear, circumstantial, tangential, flight of ideas, disorganized |
| Thought content | Preoccupations, delusions, obsessions, and suicidal or homicidal ideation with intent, plan and means |
| Perception | Hallucinations in any modality, illusions, derealization or depersonalization |
| Cognition, insight and judgement | Orientation, attention, memory, and whether the patient understands their situation and can act on it |
MSE example: routine medication follow-up
Twenty-minute visit, stable on treatment, no change in presentation.
- Appearance and behavior. Casually dressed, well groomed, appears stated age. Good eye contact, cooperative throughout, no abnormal movements.
- Speech. Normal rate, volume and rhythm. Spontaneous, no latency.
- Mood and affect. Mood reported as "pretty steady, better than last time." Affect full range, reactive, congruent with stated mood.
- Thought process and content. Linear and goal-directed. No delusions elicited. Denies suicidal or homicidal ideation, no intent, no plan, no access to means beyond household items.
- Perception. No auditory or visual hallucinations reported or observed.
- Cognition, insight and judgement. Alert and oriented to person, place, time and situation. Attention and recent memory intact for the interview. Insight into diagnosis and treatment is good; judgement intact, reports taking medication as prescribed.
MSE example: depressive presentation
Follow-up after a reported worsening between visits.
- Appearance and behavior. Appears older than stated age. Hair unwashed, wearing the same clothing described at the previous visit. Minimal eye contact, psychomotor slowing evident, sat with shoulders forward for most of the interview.
- Speech. Reduced rate and volume, increased latency before answers, mostly monosyllabic until asked open questions about work.
- Mood and affect. Mood reported as "empty, I don't really feel anything." Affect constricted with limited reactivity, tearful once when discussing the family visit, otherwise flat. Affect broadly congruent with reported mood.
- Thought process and content. Linear but slowed, with increased latency rather than derailment. Content preoccupied with themes of failure and being a burden. Passive suicidal ideation present: reports thinking "it would be easier not to be here" several times in the past week. Denies intent, denies plan, denies access to firearms. Identifies daughter as a protective factor.
- Perception. No hallucinations reported or observed.
- Cognition, insight and judgement. Alert and oriented in all spheres. Attention reduced, required two repetitions of the medication instructions. Insight partial: recognizes symptoms have worsened but attributes it entirely to circumstances. Judgement intact for safety, agreed to the safety plan and to call before making changes to medication.
MSE example: acute psychotic presentation
Urgent visit, brought in by a family member.
- Appearance and behavior. Disheveled, wearing multiple layers despite the weather. Guarded, scanned the room repeatedly, would not sit with back to the door. Cooperative with questions after several minutes, no aggression during the encounter.
- Speech. Increased rate, difficult to interrupt at points, normal volume. Occasional loss of the thread mid-sentence.
- Mood and affect. Mood reported as "fine, I just need people to listen." Affect anxious and suspicious, restricted range, incongruent with the stated mood.
- Thought process and content. Tangential, returned to the original topic only with redirection. Content includes a persecutory belief that neighbors are coordinating surveillance, held with fixed conviction and not amenable to reasoning. Denies suicidal ideation. Denies intent to harm the named neighbors when asked directly; no plan elicited.
- Perception. Reports hearing two voices commenting on his actions, present for approximately three weeks, non-command. No visual hallucinations.
- Cognition, insight and judgement. Alert, oriented to person and place, uncertain of the date. Attention impaired. Insight absent: does not consider the beliefs to be part of an illness. Judgement impaired, had stopped medication two weeks ago without discussion.
A mental status exam template you can reuse
Copy this once and fill it after each encounter. Keeping the headings constant is what makes a change between visits visible.
| Heading | Prompt |
|---|---|
| Appearance and behavior | How did they present, and how did they act during the interview? |
| Speech | Rate, volume, latency, spontaneity |
| Mood and affect | What they said they feel, and what you saw. Do the two match? |
| Thought process and content | Form of thinking, preoccupations, and risk with intent, plan and means |
| Perception | Hallucinations in any modality, present or denied |
| Cognition, insight and judgement | Orientation, attention, memory, and whether they can act on their situation |
How the exam gets written from the visit
The exam is the part of a psychiatric note that comes from observation rather than from the patient's report, which is exactly why it is slow to type afterwards: you are reconstructing from memory. In ClinicFrame the exam is generated from the encounter itself, so the observations you state out loud during the visit land in the exam section instead of in a narrative paragraph. Say the speech rate, name the affect, note the orientation, and the section has material to work with. You review and sign it.
For the rest of the psychiatric workflow, including risk assessment and prior authorization letters, see the AI scribe for psychiatry and medication management.
A note on the examples
The three exams above are illustrative. They do not describe real patients and contain no protected health information. Use them as structure, not as language to paste into a chart.