Free tool for clinicians

Mental Status Exam

Build the note as you go.

A mental status exam (MSE) is a structured snapshot of how a client looks, acts, feels, and thinks. What you observe starts within normal limits. What you have to ask, like mood, safety, and orientation, stays blank until you record it. Copy the note as lines or a paragraph.

1) Appearance

How does the client look?

Normal

Most of this is settled in the first few seconds: apparent age, dress, grooming and hygiene, and anything distinctive.

Age

Dress

Grooming

Notable · any that apply

Definitions
Appears stated age
Looks about as old as they are.
Appears older than stated age
Looks notably older than their age. Can follow long illness, substance use, or hardship.
Appropriately dressed
Clothing fits the setting and the weather.
Disheveled
Clothes or hair messy and in disarray.
Eccentrically dressed
Dress that stands out in an unusual way.
Poor hygiene
Unwashed, body odor, or visibly dirty clothing.

A change from the client’s usual presentation matters more than the presentation itself, and poor grooming can come from circumstances, not illness. Write what you see, not why.

2) Behavior

How does the client engage with you?

Normal

Attitude toward you and the interview, eye contact, and distress. Context matters: someone brought in involuntarily has reasons to be guarded.

Attitude · any that apply

Eye contact

Distress

Definitions
Cooperative
Participates willingly and answers questions.
Guarded
Reluctant to share. Short answers, holds back detail.
Evasive
Sidesteps direct questions.
Withdrawn
Disengaged, offers little, hard to draw out.
Hostile
Openly angry or argumentative.
Disinhibited
Says or does socially inappropriate things.
Poor eye contact
Keep cultural norms in mind. Limited eye contact is polite in some cultures.

3) Motor activity

How does the client move?

Normal

Speed and amount of movement, gait, posture, and involuntary movements. Medication side effects tend to show up here.

Movement · any that apply

Gait

Definitions
Psychomotor agitation
Excess, restless movement: pacing, fidgeting, hand-wringing.
Psychomotor retardation
Slowed movements and reactions.
Tremor
Rhythmic shaking, often in the hands.
Tics
Sudden, repetitive movements or sounds.
Akathisia
An inner restlessness and urge to keep moving. Often an antipsychotic side effect.
Signs of tardive dyskinesia
Involuntary repetitive movements, often of the mouth and face, after long-term antipsychotic use.
Catatonic features
Markedly reduced or abnormal movement, such as holding a fixed posture.

4) Speech

How does the client talk?

Normal

How they speak, not what they say. You pick it up over the whole conversation.

Rate

Volume

Tone

Articulation

Also · any that apply

Definitions
Pressured
Rapid and hard to interrupt.
Monotone
Flat, with little rise and fall.
Dysarthric
Difficulty physically forming words.
Hyperverbal
Talks far more than usual.
Poverty of speech
Very little spontaneous speech.
Increased latency
Long pauses before answering.

5) Mood

How does the client say they feel?

To ask

Ask, then record the answer in their own words. Add a clinical term after the quote if you like.

Clinical term · ask, then record

Definitions
Euthymic
Normal, stable mood. Neither down nor elevated.
Depressed
Low or sad. Dysphoric is a broader term for unhappy or uneasy.
Irritable
Easily annoyed or angered.
Euphoric
Unusually high or expansive, out of proportion to events.

6) Affect

What emotion do you actually see?

Normal

Your observation of how the client expresses emotion: face, voice, posture. Mood is what the client tells you; affect is what you see.

Quality · any that apply

Range

Fit with mood

Fit with content

Stability

Definitions
Full range
The normal variety of expression across the conversation.
Restricted
Narrower range than expected. Also called constricted.
Blunted
Expression is markedly reduced in intensity.
Flat
Little to no emotional expression at all.
Incongruent with mood
Doesn’t match the stated mood, like saying “great” while crying.
Inappropriate to content
Doesn’t fit what’s being discussed, like laughing while describing a loss.
Labile
Shifts quickly and noticeably between emotions.

7) Thought process

How do the client’s thoughts connect?

Normal

The shape of their thinking, not its content. Can you follow how they get from one idea to the next?

Form · any that apply

Definitions
Linear and goal-directed
Ideas follow logically and reach the point.
Circumstantial
Takes detours through unnecessary detail, but gets back to the point.
Tangential
Drifts off-topic and never gets back.
Flight of ideas
Fast jumps from idea to idea with links that are hard to follow. Often comes with pressured speech.
Loose associations
No logical connection between one idea and the next. Also called derailment.
Perseverative
Keeps returning to the same idea or answer, whatever the question.
Thought blocking
Stops abruptly mid-thought and can’t pick it back up.

8) Thought content

What is the client thinking about?

To ask

The themes that come up, and above all, safety. Always ask about suicidal and homicidal thoughts and record the answer, including a denial.

Suicidal ideation · ask, then record

Homicidal ideation · ask, then record

Other content · any that apply

Definitions
Passive SI
Wishing to be dead, without thoughts of acting on it.
Active SI
Thoughts of ending one’s life. Note plan, intent, access to means, and past attempts.
Preoccupations
Themes the client keeps coming back to, like a breakup or a health worry.
Obsessions
Intrusive, unwanted thoughts that cause distress.
Paranoid ideation
Suspicion that others mean harm, short of a fixed delusion.
Ideas of reference
Believing TV, strangers, or the internet are sending personal messages.
Delusions
Fixed false beliefs held despite clear evidence, not explained by culture or religion. Persecutory, grandiose, and somatic are common types.

A line in the MSE is not a risk assessment. If the client endorses SI or HI, document a full risk assessment and safety plan separately. Duty-to-warn and duty-to-protect rules vary by state.

9) Perception

Is the client sensing things that aren’t there?

To ask

Ask directly, and watch as well. Some clients deny hallucinations they’re having.

Hallucinations · any that apply · ask, then record

Internal stimuli

Also · any that apply

Definitions
Auditory hallucinations
Hearing sounds or voices with no external source. With visual, the most common type.
Command hallucinations
Voices telling the client to do something. Always ask what they say.
Appears to be responding to internal stimuli
Reacts to things no one else perceives, like talking to someone who isn’t there.
Illusions
Misperceiving something real, like hearing your name in background noise.
Depersonalization
Feeling detached from yourself.
Derealization
Feeling that your surroundings aren’t real.

Hallucinations while falling asleep (hypnagogic) or waking up (hypnopompic) are common and usually not a sign of illness. Cultural and religious context also matters.

10) Cognition

How well is the client thinking?

To ask

Most of this you can judge from the conversation. Test directly when something seems off: serial 7s from 100, spelling WORLD backward, or recalling three words after a few minutes.

Consciousness

Orientation · ask, then record

Attention · ask, then record

Memory · any that apply · ask, then record

Abstraction · ask, then record

Definitions
Alert
Fully awake and responsive.
Drowsy
Somnolent: sleepy, but easy to rouse.
Obtunded
Hard to rouse and slow to respond.
Stuporous
Responds only to strong stimulation.
Oriented x4
Knows who they are, where they are, the date, and the situation. Written A&Ox4.
Abstract reasoning intact
Can explain how two things are alike, or what a proverb means.
Concrete thinking
Very literal answers to abstract questions.

If cognition looks impaired, a scored screening tool such as the MMSE, MoCA, or Mini-Cog gives you a number to track.

11) Insight

Does the client understand what’s going on?

Normal

Their awareness that something is wrong and that it may need treatment. On follow-ups, note whether it’s improving.

Insight

Definitions
Good
“My anxiety is hurting my work and I want help with it.”
Limited
Admits to stress but blames others and sees no need for help.
Poor
No awareness of a problem that’s plain to everyone else.

12) Judgment

Does the client make sound decisions?

Normal

Recent real decisions, like taking medication or keeping appointments, usually tell you more than hypothetical questions.

Judgment

Examples

Two made-up clients, written by the builder above. Open either one to edit it.

A normal MSE

A routine visit with every part assessed. Even when everything is within normal limits, write each line. “Denies SI” is a finding.

Appearance: Appears stated age, casually dressed, well-groomed.

Behavior: Cooperative and engaged, good eye contact, no acute distress.

Motor: No psychomotor agitation or retardation, steady gait.

Speech: Normal rate, volume, and tone, clear articulation.

Mood: “Doing okay, a little tired.” (euthymic).

Affect: Euthymic, full range, congruent with mood, appropriate to content.

Thought process: Linear and goal-directed.

Thought content: Denies SI and HI, no delusions, obsessions, or preoccupations elicited.

Perception: Denies AH and VH, not responding to internal stimuli.

Cognition: Alert and oriented x4, attention, memory, and abstract reasoning intact.

Insight: Good.

Judgment: Good.

As a paragraph

Client appears stated age, is casually dressed, and is well-groomed. Client is cooperative and engaged, makes good eye contact, and is in no acute distress. Motor activity shows no psychomotor agitation or retardation and a steady gait. Speech is normal in rate, volume, and tone and clearly articulated. Mood is described as “Doing okay, a little tired.” (euthymic). Affect is euthymic, full range, congruent with mood, and appropriate to content. Thought process is linear and goal-directed. Client denies suicidal and homicidal ideation and shows no evidence of delusions, obsessions, or preoccupations. Client denies auditory and visual hallucinations and does not appear to be responding to internal stimuli. Client is alert and oriented x4, with intact attention, memory, and abstract reasoning. Insight and judgment are good.

An MSE with depression

A fictional intake: a client in their fifties, seen two months after losing their job.

Appearance: Appears older than stated age, disheveled, fair hygiene. Clothes wrinkled, hair unwashed.

Behavior: Cooperative and withdrawn, poor eye contact, mild distress.

Motor: Psychomotor retardation, steady gait.

Speech: Slow, soft, monotone, clear articulation, increased latency.

Mood: “Empty. I don’t really see the point.” (depressed).

Affect: Dysphoric and tearful, restricted, congruent with mood, appropriate to content.

Thought process: Linear and goal-directed but slowed.

Thought content: Passive SI, denies HI, hopelessness and guilt. “Sometimes I wish I wouldn’t wake up.” Denies plan, intent, or past attempts.

Perception: Denies AH and VH, not responding to internal stimuli.

Cognition: Alert and oriented x4, attention and delayed recall impaired, abstract reasoning intact. Serial 7s: 3 of 5 correct. Recalled 2 of 3 words at five minutes, 3 of 3 with cues.

Insight: Fair. Recognizes depression, unsure treatment will help.

Judgment: Fair. Keeping appointments, but has stopped opening bills.

As a paragraph

Client appears older than stated age, is disheveled, and has fair hygiene. Clothes wrinkled, hair unwashed. Client is cooperative and withdrawn, makes poor eye contact, and appears mildly distressed. Motor activity shows psychomotor retardation and a steady gait. Speech is slow, soft, monotone, clearly articulated, and marked by increased latency. Mood is described as “Empty. I don’t really see the point.” (depressed). Affect is dysphoric and tearful, restricted, congruent with mood, and appropriate to content. Thought process is linear and goal-directed but slowed. Client endorses passive suicidal ideation, denies homicidal ideation, and expresses hopelessness and guilt. “Sometimes I wish I wouldn’t wake up.” Denies plan, intent, or past attempts. Client denies auditory and visual hallucinations and does not appear to be responding to internal stimuli. Client is alert and oriented x4, with impaired attention and delayed recall and intact abstract reasoning. Serial 7s: 3 of 5 correct. Recalled 2 of 3 words at five minutes, 3 of 3 with cues. Insight is fair. Recognizes depression, unsure treatment will help. Judgment is fair. Keeping appointments, but has stopped opening bills.

Because the client endorsed passive SI, the intake also includes a separate risk assessment and a safety plan.

Abbreviations

The ones you’ll see most in MSE write-ups. When in doubt, spell it out.

A&Ox4
Alert and oriented to person, place, time, and situation
WNL
Within normal limits
NAD
No acute distress
SI / HI
Suicidal ideation / homicidal ideation
AH / VH
Auditory hallucinations / visual hallucinations
RIS
Responding to internal stimuli
PMA / PMR
Psychomotor agitation / psychomotor retardation
FOI
Flight of ideas
LOA
Loosening of associations

Where it goes in your notes

At intake, a full MSE is part of the diagnostic evaluation billed as CPT 90791. It’s your baseline, so complete every part.

In progress notes, a few lines are enough: mood, affect, thought process, safety, and anything that changed. It goes under Objective in a SOAP note and under Data in a DAP note. More in our guide to writing SOAP notes.

In a crisis, do a full MSE again. It supports crisis psychotherapy (90839), and the crisis intervention note has room for it.

Prefer a printable form? The mental status exam template has every section with the common options, ready to download as a PDF.

Questions

What is a mental status exam?

A mental status exam (MSE) is a structured description of how a client looks, behaves, feels, and thinks at the time you see them. It is mostly observation, gathered during the clinical interview and written up in standard terms, so another clinician can picture the client and compare against later visits.

What are the components of a mental status exam?

There are twelve: appearance, behavior, motor activity, speech, mood, affect, thought process, thought content, perception, cognition, insight, and judgment. Some clinicians fold motor activity into behavior or list safety (suicidal and homicidal ideation) as its own heading. The content is the same.

What is the difference between mood and affect?

Mood is what the client tells you they feel, recorded in their own words. Affect is what you observe of their emotional expression. When the two don’t match, like a client who says they’re fine while crying, write that down as incongruent affect.

Is the mental status exam the same as the MMSE?

No. The mental status exam describes a client’s whole mental state in words. The Mini-Mental State Examination (MMSE) is a scored 30-point screening test for cognitive impairment. A clinician might give the MMSE, or the MoCA, as a follow-up when the cognition section of the MSE raises concern.

When should a therapist do a mental status exam?

At intake, where it is part of the psychiatric diagnostic evaluation billed as CPT 90791. Many clinicians also include a brief MSE in each progress note to track change over time, and a full one whenever a client presents differently or in crisis.

Do I have to formally test every part?

No. Appearance, behavior, speech, affect, and thought process come from watching and listening. Ask directly about mood, safety, and perception. Formal cognitive tests like serial 7s or three-word recall are worth doing when something seems off, or when the presentation calls for it.

Is this mental status exam builder private?

Yes. It runs entirely in your browser. Nothing you select or type is saved or sent anywhere, and it all disappears when you close the page.

What does A&Ox4 mean?

Alert and oriented times four: the client is awake and knows who they are, where they are, the date, and the situation. Some clinicians use x3 and leave out the situation.

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Sources

  1. Voss RM, Das JM. Mental Status Examination. In: StatPearls. StatPearls Publishing; updated April 30, 2024. Link
  2. Norris DR, Clark MS, Shipley S. The Mental Status Examination. Am Fam Physician. 2016;94(8):635-641. Link

A documentation aid for licensed clinicians, reviewed October 13, 2026. It isn’t clinical advice and doesn’t replace training, supervision, or your own judgment.