Open a hundred psychiatric notes and you will find this line in most of them:

Mood: depressed. Affect: depressed.

That is not two findings. It is one interpretation written twice, and it tells a reviewer that whoever wrote it did not treat mood and affect as different fields. They are different fields, and the rule separating them is written down plainly in the reference that ranks first for this exam.

Here is the blank template, the descriptor words for every domain, three worked examples at different acuity, and the one distinction that fixes that line.

Key Takeaway: A mental status exam is the structured record of a patient's mental functioning at a single point in time, covering appearance, behavior, attitude, speech, mood, affect, thought process, thought content, perception, cognition, and insight and judgment [1]. It is the psychiatric equivalent of the physical exam: an observation, not a questionnaire, and not a scored test. The distinction that decides whether the note is defensible sits between two adjacent fields. Mood is the patient's subjective description of their feelings in their own words, documented with quotations transcribing the response verbatim. Affect is the clinician's interpretation of the patient's observed expression through their non-verbal language [1]. One is quoted, the other is observed. Sully.ai's AI Scribe captures what the patient says and what the clinician describes observing, and writes both into the note.

What a Mental Status Exam Template Covers

The mental status exam is the psychiatric physical exam.

It records what you observed during this encounter. Not what the patient reported about last week, and not what you concluded afterward. Family physicians are expected to perform and document it too, well outside psychiatry, whenever mental status is in question [2].

The Domains and the Words That Go in Each

Eleven domains, in a conventional order. Medical student training groups the first three under the mnemonic GABA, for General Appearance, Behavior and Attitude [3].

The vocabulary matters more here than in any other part of the chart. "Restricted" and "labile" are terms with agreed meanings that another clinician can picture [1][3]. "Appropriate" is not.

Mood Is Quoted, Affect Is Observed

Here is the part almost nobody operationalizes, quoted directly from StatPearls.

On mood: "Mood is a patient's subjective description of their feelings in their own words. The mood is determined by directly asking the patient to describe their feelings in their own words. Mood is documented with quotations transcribing the patient's response verbatim" [1].

On affect: "Affect is described as the clinician's interpretation of a patient's observed expression through their non-verbal language" [1].

Read those together and three rules fall out.

One. The mood field should have quotation marks in it. If it does not, you wrote an interpretation and filed it as a patient report.

Two. Affect belongs in descriptor terms, chosen from the accepted vocabulary: euthymic, restricted, blunted, flat, broad, labile, bright, elated, congruent or incongruent with the stated mood [1].

Three. The same word in both fields is self-contradicting. It claims that the patient's verbatim words and your independent observation happened to land on identical clinical vocabulary. That almost never happens. Patients say "wrung out," or "like I'm wading through wet sand." Clinicians write "restricted, reactive."

Underneath all of it is the same split that governs the rest of the chart, the one a SOAP note is built on. Mood is the subjective. Affect is the objective. A note that collapses them has no objective psychiatric exam in it at all, however long it runs.

What the Mental Status Exam Is Not

Two things get confused with it, and both confusions send people to the wrong document.

It is not the Mini-Mental State Examination. The MMSE is a separate, scored cognitive screening instrument, published commercially by PAR [4]. The mental status exam is a structured clinical observation with no score. They overlap in one of eleven domains, so a completed cognitive screen does not stand in for an exam. Mental status assessment in the neurologic sense covers orientation, attention, memory and language as its own territory [5].

It is not a psychiatric intake evaluation. An intake contains an MSE, then adds history, diagnosis, formulation and a treatment plan. The exam is one section of it.

The Mental Status Exam Template

Copy this. The quotation marks on the mood line are deliberate.

The Blank Template to Copy

MENTAL STATUS EXAMINATION

• Appearance: (apparent age against stated age, dress, grooming, hygiene, notable physical findings)

• Behavior: (posture, eye contact, psychomotor activity, mannerisms)

• Attitude: (cooperative, guarded, evasive, hostile, apathetic)

• Speech: (rate, volume, prosody, latency)

• Mood: "[the patient's exact words go here]"

• Affect: (descriptor term, then congruent or incongruent with stated mood)

• Thought process: (linear, circumstantial, tangential, loose associations, blocking)

• Thought content: (preoccupations, obsessions, delusions with type named)

• Perception: (hallucinations by modality, illusions, depersonalization, derealization)

• Cognition: (orientation, attention, memory, fund of knowledge)

• Insight: (intact, fair, limited, poor, and why)

• Judgment: (intact, fair, limited, poor, and why)

• Risk: (what you asked about suicidal and homicidal ideation, and what the patient said)

The parentheses are prompts, not text to keep. Delete them as you fill each field.

Two things in that block are deliberate. The mood field is the only one wrapped in quotation marks, because it is the only field that holds the patient's words rather than yours. Keep the quote marks when you replace the placeholder. And insight and judgment both end in "and why," because a single adjective in either field is not a finding.

Leave out a domain you did not assess rather than writing a default into it. A blank field is honest. "Within normal limits" on a domain nobody tested is a claim.

The Descriptor Words for Each Domain

This is the part worth bookmarking. These are the accepted terms, by domain [1][3].

Appearance. Apparent age against stated age, body habitus, dress, grooming, hygiene, and physical findings such as bruises, needle marks, tremor or pupil size.

Behavior. Posture, eye contact, psychomotor activity, mannerisms, tics. Specific terms: psychomotor retardation, psychomotor agitation, akathisia (inner restlessness with an inability to stay still), automatism (spontaneous verbal or motor behavior without awareness), catatonia [3].

Attitude. Cooperative, engaged, guarded, evasive, hostile, suspicious, seductive, or apathetic.

Speech. The mechanics, not the content. Rate, volume, prosody, latency of response, spontaneity. Pressured, slowed, monotone, impoverished.

Mood. The patient's words, in quotation marks.

Affect. Euthymic, dysphoric, restricted, constricted, blunted, flat, broad, labile, anxious, bright, elated, euphoric. Then a congruence judgment: congruent or incongruent with the stated mood.

Thought process. How the thoughts connect. Linear and goal directed, circumstantial, tangential, loose associations, flight of ideas, thought blocking, perseveration.

Thought content. What occupies them. Preoccupations, ruminations, obsessions, delusions with the type named, and suicidal or homicidal ideation.

Perception. Hallucinations named by modality (auditory, visual, olfactory, tactile, gustatory), illusions, depersonalization, derealization.

Cognition. Orientation to person, place, time and situation. Attention and concentration. Immediate, recent and remote memory. Fund of knowledge.

Insight and judgment. Intact, fair, limited or poor, each with a reason attached. "Limited insight, attributes the admission entirely to his employer" says something. "Insight: poor" does not.

Where Sully.ai Fits in Mental Status Documentation

The mental status exam is built almost entirely from the first two minutes of an encounter, before anyone has started typing. Speech latency. Whether the patient tracked the question. Psychomotor activity. The exact words they used when you asked how they had been.

By the time the note is written, the clinician reliably remembers the conclusion and not the observation that produced it. The mood quote is the first thing to go, because a quote is the one thing memory cannot approximate.

Sully.ai's AI Scribe captures what the patient says and what the clinician describes out loud during the encounter, and writes it into the note in the structure the clinician has saved. It runs on a single integration across Epic, Cerner, Meditech and Athenahealth.

Now the boundary, and on this topic it is sharper than on any other.

An ambient scribe hears the room. It does not see it.

Speech rate, volume, latency and prosody are audible, and so is everything the patient says. Psychomotor retardation, grooming, eye contact, tremor and posture are not. Those domains stay yours to observe and, if you want them captured, to say out loud. A scribe that filled in an appearance line on its own would be inventing a clinical observation, and on a psychiatric note that is the one failure that cannot be defended afterward.

So the honest split is: the scribe protects the mood quote and the speech findings. You still do the looking.

Sully operates across 5,000+ providers, has delivered 50M+ hours of AI work, and prices each AI role 80 to 90 percent below the human equivalent [6].

Mental Status Exam Examples Written Out

Three encounters at different acuity. Same eleven domains every time.

A Routine Outpatient Follow-Up

Bipolar II disorder, maintenance visit, stable for eight months. A behavioral health follow-up.

Appearance: Casually dressed, well groomed, appears stated age. No tremor. No psychomotor abnormality. Behavior: Seated comfortably, good eye contact, no restlessness or fidgeting. Attitude: Cooperative and engaged, volunteers information. Speech: Normal rate, volume and prosody. No latency. Mood: "Pretty level, honestly. Boring in a good way." Affect: Euthymic, full range, reactive, congruent with stated mood. Thought process: Linear and goal directed. Thought content: No preoccupations, no delusions. Denies suicidal or homicidal ideation. Perception: No hallucinations reported or observed. Cognition: Alert and oriented to person, place, time and situation. Attention intact through the interview. Insight: Intact. Identifies sleep loss as his earliest relapse signal and tracks it. Judgment: Intact. Contacted the clinic himself when he missed two doses. Risk: Asked directly about thoughts of harming himself or others. Denies both. No plan, no intent, no access concerns raised.

Notice that this normal exam is still specific. "Casually dressed, well groomed" beats "appropriate." "Boring in a good way" is a real quote and is worth more than the word euthymic on its own.

An Acute Presentation With Abnormal Findings

First presentation, 22 year old brought in by family, three weeks of change.

Appearance: Appears younger than stated age. Unwashed, wearing a winter coat indoors, several days of beard growth. No obvious injury. Behavior: Minimal eye contact, scans the corners of the room repeatedly. Psychomotor activity increased, taps the arm of the chair throughout. Attitude: Guarded. Answers briefly and asks twice who will read the notes. Speech: Normal rate, reduced volume, increased latency of about three seconds before most answers. Mood: "I'm fine. Everyone else has the problem." Affect: Restricted and incongruent with stated mood. Appears frightened rather than fine. Thought process: Tangential. Returns to the subject of surveillance without being asked, does not come back to the original question unaided. Thought content: Persecutory delusion, believes a neighbor has placed cameras in the ceiling. No suicidal ideation on direct questioning. No homicidal ideation, but states he "would have to do something" if the cameras were confirmed. Perception: Reports hearing two voices commenting on his actions, present most days for the last two weeks. No visual hallucinations reported. Cognition:Oriented to person, place and time. Attention impaired, loses the thread on serial sevens after three subtractions. Insight: Absent. Does not consider illness as an explanation. Judgment: Impaired. Has stopped eating food from his own kitchen. Risk: Asked directly about self-harm and harm to others. Denies suicidal ideation. Conditional statement regarding the neighbor documented above and escalated to the on-call psychiatrist at 14:20.

Look at the mood and affect pair. The mood is a quote that says he is fine. The affect line records that he did not look fine, and names the mismatch. Those two lines together carry more clinical information than either does alone, and you only get that by keeping them separate.

What Changes in an Emergency Setting

Same domains, compressed, weighted toward orientation, risk and capacity.

Appearance and behavior: Disheveled, malodorous, lying on the trolley with eyes closed, rouses to voice. Speech: Slurred, slowed, reduced volume. Mood: "Leave me alone." Affect: Irritable, restricted. Thought process: Disorganized, cannot sustain a sentence to completion. Cognition: Oriented to person only. Not oriented to place, time or situation. Cannot register three words. Insight and judgment: Both impaired, unable to engage with the question of admission. Risk: Unable to give a reliable account. Not safe for discharge. Continuous observation ordered at 03:10.

In the emergency setting the exam is doing triage work. The orientation findings and the risk line are the two that determine what happens next, and everything else is supporting detail.

The Findings That Get Notes Returned

Descriptors With No Supporting Observation

"Affect: appropriate" asserts nothing a second reader can check.

Compare it with "affect restricted, brightened when discussing his daughter, congruent with stated mood." One of those is a conclusion. The other is an observation with a conclusion attached, and only the second one survives someone asking how you knew.

The test is simple. Could another clinician read your line and picture what you saw in the room? "Unremarkable," "appropriate" and "within normal limits" fail it in every domain. Family medicine documentation guidance makes the same point about mental status recording outside psychiatry [2].

The Risk Line That Has to Be There

Suicidal and homicidal ideation should be addressed explicitly in every psychiatric mental status exam, including when the answer is no [1].

A bare "denies SI/HI" is the weakest defensible version. Better is a line that records what was asked and what came back: "Asked directly about thoughts of harming himself or others. Denies both. No plan, no intent."

That difference costs six seconds to write and is the single most consequential line on the form.

Book a demo and bring last week's psychiatric notes. The question worth asking is how many mood fields have quotation marks in them.

FAQ

Q: What is included in a mental status exam? Eleven domains: appearance, behavior, attitude, speech, mood, affect, thought process, thought content, perception, cognition, and insight and judgment, with a risk assessment recorded alongside them [1]. What you record in each depends on what you observed during that encounter, and the full blank template is on this page.

Q: What is the difference between mood and affect? Mood is the patient's subjective description of their feelings in their own words, documented with quotation marks transcribing the response verbatim. Affect is the clinician's interpretation of the patient's observed expression through their non-verbal language, recorded in descriptor terms such as euthymic, restricted, blunted or labile [1]. Mood is reported to you, affect is observed by you, and writing the same word in both fields is the most common error on the form.

Q: Is the mental status exam the same as the Mini-Mental State Examination? No. The mental status exam is a structured clinical observation across eleven domains with no score. The Mini-Mental State Examination is a separate scored cognitive screening instrument sold commercially by PAR [4]. They overlap only in the cognition domain, so a completed MMSE does not replace a mental status exam.

Q: How do you write a mental status exam? Work through the domains in order, record what you observed rather than what you concluded, quote the mood verbatim, pick affect from the accepted descriptor vocabulary and attach a congruence judgment, and give insight and judgment a reason rather than a single adjective. There are three worked examples on this page at routine, acute and emergency acuity.

Q: Do you have a free mental status exam template? Yes. The blank template and the full descriptor vocabulary are both on this page as copy-paste blocks, with three worked examples. Sully.ai's AI Scribe can also capture what the patient says and what you describe observing, and write the exam into the note in the structure you have saved.

Sources

[1] StatPearls, National Center for Biotechnology Information — Mental Status Examination [2] American Academy of Family Physicians — The Mental Status Examination [3] Association of Directors of Medical Student Education in Psychiatry — Mental Status Exam Definitions [4] PAR — Mini-Mental State Examination, 2nd Edition [5] Merck Manuals Professional Edition — How to Assess Mental Status [6] Sully.ai — The AI Workforce for Healthcare