Mental Status Exam Template

The Mental Status Exam template is a comprehensive documentation tool for capturing a patient's cognitive and emotional presentation at the time of the encounter. With dedicated sections for appearance, behavior, speech, mood, affect, thought process, thought content, perception, cognition, and insight and judgment, it prompts clinicians through every domain of the exam, including explicit documentation of normal findings and safety-critical details like suicidal and homicidal ideation.

It's especially valuable for psychiatric intakes, therapy sessions, and follow-up visits where tracking changes in mental status over time informs diagnosis and treatment planning. By keeping every exam in the same 10-part structure, the template produces notes that are easy to compare across visits, clear to other providers, and defensible under review. Optimized for use with Sully.ai's AI medical scribe, it turns each session into a complete, structured MSE ready for clinician review.