For use by a variety of clinicians, this template provides a mental status examination (MSE) for a client or patient after their session. Even when NovoNote cannot ascertain the individual’s status on one or more of the MSE domains, it will print out all the sub-headings for the clinician to consider and edit as required. The output from this template is suitable for inserting into other session notes or letters / reports.
Mental Status Examination (MSE)
Appearance: Describe the patient’s general physical appearance, hygiene, grooming, and attire.
Behaviour: Describe the patient’s interaction with their surrounds, activity level, psychomotor activity, eye contact, and rapport.
Speech: Describe the rate, volume, tone, coherence, and articulation of the patient’s speech.
Mood and Affect: Describe the patient’s reported mood and emotional state using their own words if possible. Describe the range and appropriateness of the patient’s emotional response during the appointment, and note any discrepancies with the patient’s stated mood. Note any observations about emotional expression made by the clinician.
Thought Process: Describe the patient’s coherence, organisation, and flow of thoughts.
Thought Content: Describe the content of the patient’s thoughts, and note the presence of delusions, distortions, obsessions, or intrusive thoughts, if any.
Perception: Describe hallucinations or other perceptual disturbances of the patient, if any.
Cognition: Describe the patient’s orientation to time / place / person, attention, memory, concentration, and comprehension.
Insight and Judgment: Describe the patient’s understanding of their mental health condition and their decision-making capacity, noting any lack of awareness or denial.
Mental Status Examination (MSE)
Appearance:
Behaviour: Restless with frequent position changes. Psychomotor agitation evident when discussing work stressors. Rapport maintained despite variable engagement.
Speech: Slightly accelerated rate, especially when describing work concerns. Normal volume and articulation. Content remained coherent despite increased speed.
Mood and Affect: Self-reported as “stressed and on edge.” Affect constricted, predominantly anxious with brief appropriate humour.
Thought Process: Logical progression with occasional circumstantiality regarding workplace issues. No thought blocking. Minimal tangentiality when anxious, responsive to redirection.
Thought Content: Preoccupied with work performance and catastrophic predictions about job loss. Ruminative thinking about perceived failures. Some cognitive distortions including mind-reading. Denies suicidal/homicidal ideation.
Perception: No hallucinations evident. Reports occasional misinterpretation of social cues when anxious, with intact reality testing.
Cognition: Fully oriented. Variable attention with some distractibility. Intact working memory and recall.
Insight and Judgment: Moderate insight into anxiety symptoms, recognising stress-symptom connection but minimising impact of sleep disruption. Good judgment regarding treatment need but overestimates ability to self-manage. Receptive to psychoeducation.
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