In Brief
Conducting a thorough psychiatric evaluation requires more than just asking questions and jotting down the client's responses. To truly grasp a person's mental state, you need a complete set of tools and sharp observation skills.
One such tool, often seen as the backbone of any psychiatric assessment, is the mental status exam (MSE). The MSE offers extensive information about a client's cognitive functioning, emotional state, and behavioral patterns. But an MSE is only as good as how it’s documented, so let’s explore the importance of using precise language in your notes, as well as some reminders about the MSE in general. We will also provide practical examples of MSE descriptors to help you create accurate, insightful documentation. So let’s get into it.
What is a Mental Status Exam
The mental status exam provides a structured way to observe and describe a person's psychological functioning at a specific time. It involves noting the client's behavior, appearance, attitude, mood, affect, speech, thought process, thought content, perception, cognition, insight, and judgment.
What Documentation is Required for a Mental Status Exam
Writing a mental status exam correctly is important for accurate clinical assessment, diagnosis, and treatment planning. Here are the key components to include in your MSE documentation:
- General Appearance and Behavior: Observe and record the patient's overall demeanor, including dressing, hygiene, posture, and any notable behaviors. Note if the patient appears well-groomed or unkempt and whether their clothes are appropriate for the weather and situation.
- Affect: Assess the patient's affect through facial expressions, tone of voice, and body language. Describe the affect in terms of range (restricted, broad), intensity (blunted, intense), and appropriateness to the context.
- Speech: Evaluate the patient's speech for characteristics such as normal, pressured, or slurred. Note the rate, tone, and latency of speech.
- Thought Process and Content: Document whether the patient's thought process is goal-directed and logical or disorganized. Note any signs of thought disorder, delusions, hallucinations, phobias, obsessions, and suicidal or homicidal ideation.
- Orientation and Memory: Determine if the patient is oriented to time, place, and person. Assess remote, recent, and immediate memory using tasks such as recalling past events, remembering three objects after a few minutes, and performing digit span.
- Perception, Concentration, and Abstract Thought: Check for any signs of perceptual disturbances, test concentration using tasks like serial 7's or spelling "WORLD" backward, and assess the patient's ability to interpret proverbs or understand abstract concepts.
- Insight and Judgment: Evaluate the patient's insight into their condition and their judgment by asking scenario-based questions.
Why Language is Important for Exam Notes
The language you use in your mental status exam notes can greatly affect the quality of care, treatment plan creation, and clinical outcomes. Here are some key reasons why precise, clear language matters:
- Emotional impact: The words you choose can evoke positive or negative emotions and influence the thoughts and actions of other involved healthcare providers. Accurate, neutral, objective language helps prevent negative impressions that could skew perceptions.
- Accuracy and clarity: Ambiguous or repetitive language can lead to misinterpretation, undue labels, stigma, and bias. Be mindful of your word choice to ensure your documentation accurately reflects the patient's condition and care.
- Inclusive language: Using inclusive, person-first language (e.g., "a person with depression" instead of "a depressed person") helps create a supportive environment and reduces negative connotations associated with certain terms.
- Cultural sensitivity: Cultural norms and values significantly influence how individuals express themselves, interpret their experiences, and behave in clinical settings. Without cultural awareness, there is a risk of misinterpreting or pathologizing behaviors that are culturally appropriate or typical.
- Clinical implications: The language used in documentation can influence treatment plans and patient care. Accurate, clear notes ensure that patients receive appropriate and effective care.
Words and Descriptors to Include for Each Section of Your MSE Documentation
When conducting a mental status exam, using precise, descriptive language is important for capturing the nuances of your client's presentation. Here are some key sections of the MSE and examples of words and phrases to include in your documentation:
Appearance
- Well-groomed
- Disheveled
- Casual
- Eccentric
- Age-appropriate
- Dressed appropriate to weather
- Bizarre
- Unkempt
- Neat
- Clean
- Stylish
- Provocative
- Noting any distinguishing features (tattoos, scars)
Behavior
- Cooperative
- Guarded
- Agitated
- Restless
- Calm
- Hostile
- Withdrawn
- Engaging
- Defensive
- Dramatic
- Seductive
- Aggressive
- Impulsive
Speech
- Normal rate and rhythm
- Pressured
- Slow
- Rapid
- Monotone
- Loud
- Soft
- Slurred
- Mumbling
- Articulate
- Coherent
- Hesitant
- Stammering
- Latent
- Delayed
Other speech-related terms include
- Echolalia: repetition of another’s words that were just spoken
- Mutism: absence of speech
- Aphasia: inability to produce or understand language due to brain injury
Mood
- Euthymic
- Dysphoric
- Anxious
- Depressed
- Irritable
- Angry
- Euphoric
- Expansive
- Hopeless
- Guilty
- Ashamed
- Fearful
- Empty
Affect
- Appropriate
- Inappropriate
- Constricted
- Blunted
- Flat
- Labile
- Intense
- Dramatic
- Congruent with mood
- Incongruent
Thought Process
- Logical
- Goal-directed
- Circumstantial
- Tangential
- Loose associations
- Flight of ideas
- Perseveration
- Blocking
- Concrete
- Abstract
Thought Content
- Delusions (grandiose, persecutory, referential)
- Obsessions
- Compulsions
- Phobias
- Suicidal ideation
- Homicidal ideation
- Paranoia
- Ideas of reference
- Poverty of content
- Preoccupation
- Magical thinking
- Intrusive thoughts
- Rumination
Perception
- Hallucinations (auditory, visual, tactile, olfactory, gustatory)
- Illusions
- Depersonalization
- Derealization
Cognition
- Alert
- Oriented (person, place, time, situation)
- Attentive
- Distractible
- Poor concentration
- Impaired memory (immediate, recent, remote)
- Impaired judgment, limited insight
- Intellectual functioning (average, below average, above average)
Insight and Judgment
- Good
- Fair
- Poor
- Absent
- Acknowledges problem
- Minimizes
- Rationalizes
- Denies
- Understands consequences
- Impulsive
- Risk-taking
The goal is to paint a vivid picture of your client's mental state using objective, non-judgmental language. Incorporating these descriptors into your MSE notes will create a more comprehensive and useful record of your client's presentation.
Example of a Mental Status Exam Note
Let’s put that vocabulary into action. Here's an example of a well-documented mental status exam note:
Appearance and Behavior: Jane, a 32-year-old Korean American female who is 3 months postpartum. She arrived on time for her appointment and wore casual jeans and a t-shirt, which were clean and suitable for the weather. Her hygiene was good, and she maintained an upright posture and eye contact throughout the session.
Speech: Jane's speech was clear, coherent, and at a normal rate and volume. She answered questions with minimal prompting and provided more details when asked.
Mood and Affect: Jane described feeling "anxious and overwhelmed." Her affect matched her reported mood, showing a slightly restricted range of emotions.
Thought Process and Content: Jane's thoughts were linear and purposeful. She denied experiencing delusions, hallucinations, or obsessive thoughts. Jane reported intrusive thoughts about fears related to harm coming to her infant and described gruesome images that pop in her head throughout the day. She denied suicidal ideation or thoughts to harm her baby.
Perception: No perceptual disturbances were observed or reported during the session.
Cognition: Jane was alert and oriented to person, place, time, and situation. Her attention and concentration were intact, as shown by her ability to engage in conversation and complete simple cognitive tasks. Her memory for recent and past events appeared intact.
Insight and Judgment: Jane expressed insight that her intrusive thoughts are not real, however, stated that she has difficulty allowing others to take care of the baby and does not leave the baby for more than 10 minutes at a time. The client reported her husband was in the waiting room with the baby for her comfort while she attended intake.
Key Takeaways
The mental status exam serves as a valuable tool for assessing a client's cognitive functioning, emotional state, and behavioral patterns. Using precise language and detailed descriptions helps create a comprehensive picture of your client's mental health.
Keep these key points in mind when conducting and documenting a mental status exam:
- Use a systematic approach: Follow a structured format or mnemonic to ensure you cover all important components of the MSE.
- Be specific and objective: Avoid generic phrases like "within normal limits." Instead, provide detailed, non-judgmental observations.
- Tailor the exam to your client: Customize the MSE based on your client's unique needs and circumstances.
- Compare with previous assessments: Note any changes or progress since prior exams to track treatment effectiveness.
- Use inclusive, person-first language: Choose words that respect the individual and minimize stigma.
- Cultural sensitivity: Consider the client’s cultural background and norms to avoid misinterpreting behaviors or expressions as pathological.
Incorporating these best practices into your mental status exams will lead to more accurate diagnoses, effective treatment plans, and better outcomes for your clients. By honing your observation skills and using precise, descriptive language, you can gain valuable insights into your client's mental well-being and provide the highest quality of care.
