As a practitioner, a mental status exam is a must for each patient you see. In this post, we are going to include different components of a mental status exam as well as a mental status exam template PDF that is editable. You can use our template digitally for each patient.
What is a Mental Status Exam?
A mental status examination is an important part of the clinical assessment process in a neurological and/or psychiatric practice. According to Merck Manuals, The mental status exam is an “assessment of current mental capacity through evaluation of general appearance, behavior, any unusual or bizarre beliefs and perceptions, mood, and all aspects of cognitive function.”
According to the Washington State Department of Social and Health Services, A mental status exam must include detailed observations regarding your patient’s appearance, speech, attitude, behavior, mood, and affect. If not within normal limits, the mental status exam must also include detailed observations regarding your patient’s thought process and content, orientation, perception, memory, fund of knowledge, concentration, abstract thought, insight, and judgement.
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Mental Status Exam Components to Include
Here are some examples of appearance observational questions you can answer about your patient:
- Is my patient well groomed or unkempt?
- What is my patient wearing?
- Are my patient’s clothes appropriate for the weather and the situation they are in?
Here is an example of a speech observational question you can answer about your patient:
- Is my patient’s speech normal, pressured, tangential, or circumstantial?
Attitude and Behavior
Here is an example of an Attitude and Behavior observational question you can answer about your patient:
- Is my patient calm, cooperative, uncooperative, or belligerent?
Here is an example of a mood observational question you can answer about your patient:
- Is my patient’s mood euthymic, irritable, elevated, anxious, or depressed?
Here is an example of an affect observational question you can answer about your patient:
- Is my patient’s affect within a normal range, are they depressed, constricted, flat, labile, blunted, reactive and mood congruent, or tearful?
Thought Process and Content
Here are some examples of thought process and content observational questions you can answer about your patient:
- Is my patient logical or disorganized?
- Does my patient have any delusions, phobias, or obsessions/compulsions?
- Is my patient suicidal and/or homicidal?
Here is an example of an orientation observational question you can answer about your patient:
- Is my patient oriented to time and place?
Here is an example of a perception observational question you can answer about your patient:
- Did my patient display signs of hallucinations or delusions during my interview?
Here are some examples of memory observational questions you can answer about your patient:
- Can my patient remember past events? (remote)
- Can my patient remember 3 of 3 objects after 5 minutes? (recent)
- Can my patient perform digit span? (immediate)
Fund of Knowledge
Here are some examples of fund of knowledge observational questions you can answer about your patient:
- Is my patient aware of current events? Make sure to include examples.
- Does my patient know the names of the president or other important political figure?
- Can my patient answer simple geography questions, like what are the largest cities in his/her state?
Here are some examples of concentration observational questions you can answer about your patient:
- Can my patient spell TOOTH forward and backwards?
- Can my patient count down by 7 or 3 from 100?
- Can my patient follow a 3 step command?
Here is an example of an abstract thought observational question you can answer about your patient:
- Can my patient interpret proverbs?
Insight and Judgement
Here are some examples of insight and judgement observational questions you can answer about your patient:
- Does my patient have insights into their condition?
- Does my patient show good judgement? For example, ask the patient what they would do if they smelled smoke in a crowded arena
Creating a Mental Status Exam
When it comes to obtaining a mental status exam, you can either create your own or use a templated mental status exam. While creating a custom intake form may sound like a good idea, it can be costly and also you may miss out on important questions to include. Our template allows you to fill out the form on your computer and store it electronically. This can be invaluable to organizing documents by patient in your practice.
Download our editable mental status exam pdf template:
Final Thoughts on Your Mental Status Exam
Thank you for reading our blog on what to include on your mental status exam, we hope it was of incredible value to your practice. Your mental status exam is crucial to properly assessing your patients, and a digital copy of your mental status exam is valuable to the health of your private practice. Being able to efficiently fill out and digitally store your patients’ mental status exam securely will help your private practice operate in a way that will set you up for many years of success.
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