A mental status exam template gives you a structured format for documenting all 10 components of the MSE:

1. Appearance

2. Behavior

3. Speech

4. Mood

5. Affect

6. Thought process

7. Thought content

8. Perception

9. Cognition

10. Insight and Judgment

so nothing gets missed under time pressure. Below you'll find a free downloadable PDF template, a copy-paste text version for your EHR, and a fully completed example write-up you can model your own notes on.

You can download the PDF version here.

Key Takeaways

• A complete MSE covers 10 components, and a good template prompts you through each one in a consistent order, from appearance through insight and judgment.
  
  

• Templates measurably improve documentation quality: research published in Academic Psychiatry found that structured templates improved the completeness of psychiatric documentation, particularly among residents and early-career clinicians.
  
  

• Document "normal" findings explicitly. A line like "no perceptual disturbances reported or observed" is defensible documentation; a blank section is not.
  
  

• Templates only solve half the problem. You still have to fill them in. An AI medical scribe can complete your MSE template automatically from the session itself, leaving you to review and sign.

Free Mental Status Exam Template (PDF Download)

The template below is a single-page MSE form covering all 10 components, with prompts under each section so you know exactly what to assess and document. Page two includes a completed example so you can see what a finished exam looks like in practice.

Download the Mental Status Exam Template (PDF)

Print it for the clipboard, keep it open on a second screen, or use it as the base for a smart phrase in your EHR. It works for psychiatrists, therapists, NPs, and primary care providers doing psychiatric intake or follow-up visits.

What Is a Mental Status Exam?

A mental status exam (MSE) is a structured clinical assessment of a patient's cognitive and emotional functioning at a single point in time. It's the psychiatric equivalent of the physical exam: a systematic set of observations, recorded in a standard order, that captures how the patient presents right now.

That distinction matters. The history tells you what the patient reports has happened; the MSE documents what you observe and elicit during the encounter. Together they form the backbone of the psychiatric evaluation, and the MSE is described in the clinical literature as an essential tool for diagnosis, risk assessment, and tracking change over time.

You'll typically document a full MSE at every initial evaluation, then briefer focused versions at follow-ups, expanding again whenever something changes.

The 10 Components of a Mental Status Exam

Here's the quick-reference version. Each row maps directly to a section of the template.

Record mood in the patient's exact words, in quotes, and describe affect in your own clinical language. Documenting them separately, and noting whether they're congruent, is one of the fastest markers of a well-written MSE.

Mental Status Exam Template (Copy-Paste Format)

Prefer plain text? Copy this directly into your EHR or note-taking tool. Delete the prompts as you fill each section in.

MENTAL STATUS EXAMINATION

Patient: ______________________  Date: ____________  Clinician: ______________________

APPEARANCE

[Grooming, hygiene, dress, apparent vs. stated age, notable features]

BEHAVIOR

[Eye contact, cooperation, attitude toward examiner, psychomotor activity]

SPEECH

[Rate, volume, tone, fluency, latency of response]

MOOD

[Patient's self-reported emotional state, in their own words]

AFFECT

[Observed expression: range, intensity, stability, congruence with mood]

THOUGHT PROCESS

[Linear / circumstantial / tangential / flight of ideas / loose associations]

THOUGHT CONTENT

[Delusions, obsessions, phobias, ruminations. Suicidal ideation: passive/active,

plan, intent. Homicidal ideation.]

PERCEPTION

[Hallucinations (type), illusions, depersonalization, derealization]

COGNITION

[Level of alertness, orientation x4, attention/concentration, memory,

formal testing results if performed]

INSIGHT & JUDGMENT

[Awareness of illness and need for treatment; recent decision-making]

How to Fill Out Each Section (With Example Sentences)

The template tells you what to cover. Here's how to actually write each section, with an example sentence you can adapt.

1. Appearance

Describe grooming, hygiene, dress, and whether the patient appears their stated age. Flag anything notable (a winter coat in July, signs of neglected self-care) without interpretation.

Example: "Patient is a 34-year-old male who appears his stated age, casually dressed with adequate grooming and hygiene."

2. Behavior

Document eye contact, cooperation, attitude toward the interview, and psychomotor activity. Remember that some guardedness is normal in an unfamiliar clinical setting.

Example: "Cooperative and engaged, with intermittent eye contact. Mild psychomotor restlessness noted - frequently shifting position and tapping foot."

3. Speech

Cover rate, volume, tone, and fluency. Pressured speech, long response latency, or word-finding difficulty all belong here, not under thought process.

Example: "Speech is soft and slow with increased latency of response; fluent, with no articulation difficulties."

4. Mood

Mood is subjective. It's what the patient tells you. Use their exact words in quotes, and consider a 1-10 rating for a trackable baseline.

Example: "Patient describes mood as 'anxious and worn out,' rating it 4/10 over the past two weeks."

5. Affect

Affect is objective. It's what you observe. Describe range (full, restricted, flat), stability (stable, labile), and congruence with reported mood.

Example: "Affect is restricted in range, predominantly anxious, and congruent with stated mood."

6. Thought Process

Describe the organization and flow of thinking: linear and goal-directed at one end; circumstantiality, tangentiality, flight of ideas, or loose associations at the other.

Example: "Thought process is linear and goal-directed; mildly circumstantial when discussing work stressors."

7. Thought Content

This is where risk documentation lives. Address delusions, obsessions, and ruminations; and always explicitly document suicidal and homicidal ideation, including plan and intent when present.

Example: "Ruminative worry about job security. Denies delusions and obsessions. Endorses passive suicidal ideation without plan or intent; denies homicidal ideation."

Pro tip: Never leave SI/HI implied. "Denies SI/HI" takes four words and is the single most scrutinized line in the entire exam during any chart review or legal proceeding.

8. Perception

Note hallucinations by sensory type (auditory, visual, tactile), plus illusions, depersonalization, or derealization. Document the negative finding when absent.

Example: "No hallucinations reported or observed. Denies depersonalization or derealization."

9. Cognition

Cover alertness, orientation (person, place, time, situation), attention, and memory. Include results of any formal testing: serial 7s, spelling "WORLD" backwards, three-object recall.

Example: "Alert and oriented x4. Attention intact; able to spell 'WORLD' backwards. Recalled 3/3 objects at five minutes."

10. Insight and Judgment

Insight is the patient's understanding of their condition; judgment is their capacity to make sound decisions. Rate each as good, fair/partial, or poor, with brief supporting evidence.

Example: "Good insight, recognizes symptoms as anxiety-related and is motivated for treatment. Judgment intact, evidenced by appropriate management of work and family obligations."

MSE vs. MMSE: What's the Difference?

These get confused constantly, so it's worth being precise. The mental status exam (MSE) is a broad, narrative psychiatric assessment across all 10 domains above. The Mini-Mental State Examination (MMSE) is a specific, scored 30-point screening tool for cognitive impairment — orientation, registration, attention, recall, and language — most often used in dementia and delirium workups.

If you suspect cognitive impairment during the cognition section of your MSE, that's your cue to add an MMSE or MoCA, not to substitute one for the other.

Common MSE Documentation Mistakes to Avoid

Even with a template in hand, a few errors show up in charts again and again:

• Skipping "normal" sections. An empty perception field reads as "not assessed," not "no findings." Document the negative.
  
  

• Mixing up mood and affect. Mood is reported; affect is observed. Conflating them into one line loses clinically important incongruence.
  
  

• Vague risk language. "No safety concerns" is not the same as "denies suicidal ideation, plan, or intent." Be specific, this is the line auditors and attorneys read first.
  
  

• Interpreting instead of describing. "Patient is manipulative" is a judgment; "patient made repeated requests for early medication refills" is an observation. Describe, then assess.
  
  

• Ignoring cultural context. Averted eye contact, emotional restraint, or spiritual experiences can be culturally normative rather than pathological. When unsure, ask the patient directly rather than assuming.

Frequently Asked Questions

What are the 10 components of a mental status exam? 

The 10 components are appearance, behavior, speech, mood, affect, thought process, thought content, perception, cognition, and insight and judgment. Some templates combine related domains (like mood and affect), but all 10 areas should be addressed in a complete exam.

Is a mental status exam the same as a mental state examination? 

Yes, "mental status exam" is the standard US term, while "mental state examination" is more common in the UK and Australia. Both refer to the same structured assessment.

How long does a mental status exam take? 

A comprehensive MSE typically takes 15-30 minutes as part of an initial evaluation. Much of it is observed naturally during the interview rather than asked as a checklist, and brief follow-up MSEs can take just a few minutes.

How often should I document a mental status exam? 

Complete a full MSE at every initial assessment, then a brief focused version at each follow-up. Return to a comprehensive exam whenever there's a significant change in presentation, a medication change, or a safety concern.

How do I document a normal mental status exam? 

State the normal finding explicitly for each component, for example, "Alert and oriented x4, cooperative, speech normal in rate and volume, mood 'good' with congruent full-range affect, thought process linear, no SI/HI, no perceptual disturbances, insight and judgment intact." Never leave a section blank.

Can AI write a mental status exam? 

Yes. AI scribes like Sully.ai generate a structured MSE draft directly from the recorded session. Clinicians should still review and add purely observational findings (appearance, affect, eye contact) since those aren't captured in audio. The AI draft handles the structure and the transcript-based content; you supply the clinical eyes.

Sources

1. StatPearls / NCBI Bookshelf: Mental Status Examination: clinical overview of components and technique. https://www.ncbi.nlm.nih.gov/books/NBK546682/

2. Academic Psychiatry (PMC): Study on structured templates improving psychiatric documentation quality. https://pmc.ncbi.nlm.nih.gov/articles/PMC4526540/