Q&A: Customary elements of a mental status examination

Q: What should be included in a mental status examination and is there an industry standard?

A: A mental status examination (MSE) is a standardized procedure used by practitioners to evaluate a client’s mental and emotional functioning. Practitioners may be trained to conduct an MSE as physicians and psychiatrists, but nurses, social workers with clinical training (e.g., LCSW), or counselors may do so as well. MSEs involve a precise series of observations and questions that focus on specific domains, and whether the client is within normal limits or not. For example, is the client alert and oriented to person and place but perhaps not time? Does the client present as happy but cries and verbalizes anger? Is the client concerned that messages are coming through the bedside lamp? Is the client worried the government is controlling the staff and, thus, is resistant to agree to lab work? Is the client at risk for self or public harm? Exploration of these areas using an MSE speaks volumes about the client’s overall functionality.

A completed MSE traditionally results in a brief paragraph of condensed information, though it contributes greatly to the overall diagnostic picture of the client. Although a number of MSE models exist, there is shared consensus on the customary elements, displayed below:

• Appearance, behavior, and attitude
• Characteristics of speech (e.g., rapid, flight of ideas, intelligibility)
• Affect (e.g., flat, reflective of mood)
• Mood (e.g., sad, happy)
• Thought content, thought form, and concentration (e.g., hallucinations, delusions)
• Self-harm (e.g., suicidal and/or homicidal ideation)
• Orientation (e.g., person, place, time, situation)
• Memory (e.g., short term, long term)
• General intellectual level (e.g., average for age)
• Insight (e.g., understanding of the problem, diagnosis, reason for the interview)
• Judgment (e.g., understand the consequences of actions)

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