When a patient comes to see us, we check their blood pressure and listen to their heart. But we also need to check their mind. The Mental Status Exam (MSE) is our tool for that. It is like taking a “snapshot” of how a person’s mind is working right now. This snapshot helps us see if something is wrong, like depression, anxiety, psychosis, or memory loss. The MSE is not a blood test or an X-ray. It is a series of careful observations and questions. You do it every time you talk to a patient. You just need to know what to look for. This cheat sheet will give you a simple checklist. You will also get real examples of what to write down. You can use this guide during your shift or while studying for a test.

AI-Powered • HIPAA-Ready

Clinical notes, done for you.

Skriber listens, understands, and writes SOAP notes instantly — freeing you from hours of documentation.

Start Free

Let us make this easy. We will go through each part of the MSE one by one. For each part, I will give you a checklist of things to look for. Then I will show you how to write it in a patient’s chart. Let’s get started.

Part 1: Appearance (What Do You See?)

The first thing you notice about a patient is how they look. This is not about being pretty or handsome. It is about seeing clues to their health. Do they look clean? Are they dressed for the weather? Do they look tired or sick? You do not need to ask questions for this part. Just use your eyes.

Checklist for Appearance:

• Grooming and hygiene: Is their hair clean and brushed? Do they look like they just took a shower? Or do they look dirty or smell bad?
• Dress: Are they wearing clothes that fit the season (coat in winter, shorts in summer)? Are the clothes strange (many layers, wearing a hat inside)?
• Body type: Do they look very thin, very heavy, or average? Have they lost a lot of weight recently?
• Physical signs: Do they have scars, tattoos, or marks? Do their hands shake (tremors)? Do they look pale or red in the face?

Examples of what to write:

• “Patient is a 34-year-old male. He is unshaven and wearing dirty jeans. His clothes have a strong smell of urine. He appears thin, but not starving.”
• “Patient is a 22-year-old female. She is well-groomed with clean hair and makeup. She is wearing a summer dress on a cold day. This is odd.”
• “Patient appears older than stated age. He has a large scar on his left forearm. His hands shake slightly when resting.”

Quick Table: Normal vs. Concerning Appearance

Normal Finding	Concerning Finding
Clean hair and skin	Dirty hair, body odor
Clothes match the weather	Heavy coat in summer, shorts in winter
Average body weight	Very thin (possible eating disorder)
No unusual smells	Smell of alcohol or urine

Part 2: Behavior and Attitude (How Do They Act?)

Now look at how the patient acts during the interview. Do they sit still? Do they look at you? Are they friendly or angry? This part is about their body language and how they treat you. Behavior can tell you if a person is nervous, confused, or even dangerous.

Checklist for Behavior:

• Eye contact: Do they look at your eyes normally? Do they stare too much? Do they look away the whole time?
• Motor activity: Are they calm and still? Or can they not stop moving (pacing, tapping feet)? Or are they very slow to move?
• Facial expressions: Does their face show emotion? Do they smile when happy? Or does their face stay flat like a mask?
• Attitude toward you: Are they friendly and helpful? Are they angry or suspicious? Do they act like a child (immature)?

Examples of what to write:

• “Patient made good eye contact throughout the interview. She sat still in her chair. She smiled at appropriate times. Her attitude was cooperative.”
• “Patient could not stop moving. He kept crossing and uncrossing his legs. He looked at the floor and would not look at me. He seemed very nervous.”
• “Patient sat like a statue for 20 minutes. His face did not change at all. When I asked questions, he just stared at the wall. This is called a flat affect.”

Common words to use:

• Cooperative
• Guarded (careful, not trusting)
• Hostile (angry)
• Withdrawn (quiet, keeping to self)
• Bizarre (strange, odd actions)

Part 3: Speech (How Do They Talk?)

You listen not just to the words, but to how the words come out. Is the speech fast or slow? Is it loud or quiet? Does it make sense? People with mania talk very fast. People with depression talk very slow. People with brain injury might slur their words.

Checklist for Speech:

• Rate: Too fast (pressured), normal, or too slow (slowed)?
• Volume: Whisper, normal, or very loud (shouting)?
• Tone: Flat (no emotion), normal, or dramatic? Do they sound sad or angry?
• Clarity: Clear words or slurred like they are drunk?
• Amount: Do they talk a lot (verbose) or very little (poverty of speech)?

Examples of what to write:

• “Speech is normal in rate, volume, and tone. Words are clear. Patient answers questions with full sentences.”
• “Speech is very fast and loud. It is hard to get a word in. Patient jumps from topic to topic. This is pressured speech.”
• “Speech is slow and quiet. Patient takes 10 seconds to answer each question. He uses one or two words only. This is poverty of speech.”

Mini Quiz for You: If a patient talks like a machine gun (non-stop), what mood might they have? Answer: Mania (high energy).

Part 4: Mood and Affect (What Are They Feeling?)

This part is very important. Mood is how the patient says they feel inside. You ask them directly: “How is your mood today?” Affect is what you see on their face. Sometimes these two things do not match. A person might say “I feel great” but cry while saying it. That is a mismatch.

Checklist for Mood (Ask the patient):

• Sad, depressed, or empty
• Anxious, worried, or scared
• Angry or irritable
• Happy, high, or “on top of the world”
• Numb or “nothing” (empty)

Checklist for Affect (What you observe):

• Range: Full range (smiles, frowns, cries) or restricted (very little change)?
• Intensity: Normal strength or blunted (weak) or flat (no emotion at all)?
• Stability: Stable or labile (changes very fast from laughing to crying)?
• Congruence: Does affect match mood? (Says “sad” but smiles = incongruent)

Examples of what to write:

• “Patient reports mood as ‘sad and tired.’ Affect is depressed but full range. She cries when talking about her dog. Mood and affect are congruent.”
• “Patient reports mood as ‘fine, no problems.’ But affect is flat. He shows no emotion at all. This is a mismatch.”
• “Patient reports mood as ‘anxious.’ Affect is very labile. He laughed, then cried, then got angry all in 5 minutes.”

Helpful Table: Mood Words vs. Affect Words

Mood (Patient says)	Affect (You see)
Depressed	Flat, blunted, sad face
Anxious	Worried look, tense muscles
Euphoric (very happy)	Big smiles, laughing a lot
Irritable	Frowning, angry glare
Nothing (empty)	Blank stare, no expression

Part 5: Thought Process (How Do They Think?)

This is about the form of thinking. How do ideas flow together? Do they make logical sense? Or are the thoughts jumping around in a confused way? You do not ask about the content (what they think) yet. First, look at the process (how they connect ideas).

AI-Powered • HIPAA-Ready

Let AI handle your clinical notes.

Skriber listens during the visit and creates complete SOAP notes in seconds — so you can stay focused on the patient.

• 🎙️
  Capture Ambient listening during sessions
• 📝
  Transcribe Speech → text instantly
• 📋
  Generate SOAP Accurate structured notes
• ✅
  Review & sign Edit and finalize instantly

Start Free No credit card required

Checklist for Thought Process:

• Logical and goal-directed: Thoughts make sense and go toward an answer. (Normal)
• Tangential: They go off topic and never come back.
• Circumstantial: They go off topic but eventually come back to the point.
• Flight of ideas: Thoughts jump very fast from one idea to another. Words rhyme or sound similar.
• Loosening of associations: Sentences do not connect at all. It sounds like a word salad.
• Blocking: They stop talking in the middle of a sentence and cannot continue.

Examples of what to write:

• “Thought process is logical and goal-directed. Patient answers each question clearly.”
• “Thought process is circumstantial. Patient takes a long time to answer. He gives many extra details. But he always returns to the main point.”
• “Thought process shows loosening of associations. When asked about work, patient said, ‘The moon is cheese. My foot is a tree. Go away purple.’ This is disorganized.”
• “Thought process has blocking. Patient stops talking for 30 seconds. Then she starts a new topic.”

Simple Rule: If you feel lost listening to the patient, their thought process may be disorganized.

Part 6: Thought Content (What Do They Think About?)

Now we ask about the actual ideas in their head. Are they having strange beliefs? Do they worry too much? Do they want to hurt themselves or others? This part is very serious. You must ask directly about suicide and violence. Asking does not cause harm. It saves lives.

Checklist for Thought Content:

• Delusions: Fixed, false beliefs that are not real. Example: “The FBI is following me in a green car.”
  • Paranoid: Someone is out to get them.
  • Grandiose: “I am God” or “I am a billionaire.”
  • Somatic: “My organs are rotting inside.”
• Obsessions: Repeated thoughts they cannot stop. Example: “I must wash my hands 100 times.”
• Phobias: Extreme fear of something specific. Example: Fear of spiders or leaving home.
• Suicidal thoughts: Do they want to die? Do they have a plan?
• Homicidal thoughts: Do they want to hurt someone else?

Examples of what to write:

• “Denies delusions, obsessions, or phobias. Denies suicidal or homicidal thoughts.”
• “Patient reports paranoid delusions. He believes his neighbor is poisoning his food. He has stopped eating at home.”
• “Patient admits to suicidal thoughts. She says, ‘I want to go to sleep and not wake up.’ She has no specific plan. She denies homicidal thoughts.”

Critical Safety Checklist (Ask These Every Time):

1. “Have you had thoughts of hurting yourself?”
2. “Have you had thoughts of hurting anyone else?”
3. “If yes, do you have a plan? Do you have the means (pills, gun, etc.)?”
4. “What stops you from acting on these thoughts?”

If patient says YES to any of these, do not leave them alone. Get help immediately.

Part 7: Perceptions (Are They Sensing Things Correctly?)

Perception is how the brain takes in information from the senses (hearing, seeing, feeling, smelling, tasting). Sometimes a person’s brain makes up things that are not there. These are called hallucinations. Other times they misinterpret real things (illusions).

Checklist for Perceptions:

• Hallucinations (no real stimulus):
  • Auditory: Hearing voices when no one is there. (Most common in schizophrenia)
  • Visual: Seeing things that are not there. (More common in medical problems or drug use)
  • Tactile: Feeling bugs crawling on skin. (Common in alcohol withdrawal)
  • Olfactory: Smelling bad smells like rotting fish.
  • Gustatory: Tasting something strange like metal.
• Illusions (real stimulus, wrong interpretation): Thinking a coat on a chair is a person.
• Depersonalization: Feeling unreal or detached from your own body.
• Derealization: Feeling like the world is not real, like a movie.

Examples of what to write:

• “Denies hallucinations or illusions. Perception appears intact.”
• “Patient reports auditory hallucinations. He hears two voices talking about him. The voices tell him he is bad. He has had these for three years.”
• “Patient has tactile hallucinations. She feels bugs crawling on her arms. She scratches her skin until it bleeds. No bugs are seen.”
• “Patient experiences derealization. She says, ‘The world looks like a cartoon. Nothing feels real.'”

Important: Do not argue with a patient about their hallucinations. For them, it feels very real. Just listen and document what they say.

Part 8: Cognition (How Is Their Memory and Attention?)

Cognition means brain functions like memory, attention, and knowing who and where they are. This part is very important for older adults or people with head injuries. But you should check everyone’s cognition quickly.

Checklist for Cognition:

• Alertness: Are they awake? Or drowsy, lethargic, or in a coma?
• Orientation (Ask 4 questions):
  • Person: “What is your name?”
  • Place: “Where are we right now?”
  • Time: “What is today’s date? What season is it?”
  • Situation: “Why are you here?” (Or “What is happening right now?”)
• Attention: Ask them to spell “WORLD” backwards. Or say “No ifs, ands, or buts” and have them repeat it.
• Memory:
  • Immediate: Say three words (apple, table, penny). Ask them to repeat now.
  • Short-term: Ask them to recall those three words after 3-5 minutes.
  • Long-term: “What high school did you go to?” “When is your birthday?”
• Abstract thinking: “What do a train and a car have in common?” (Both are transportation). “What does ‘people in glass houses should not throw stones’ mean?”

Examples of what to write:

• “Patient is alert and oriented to person, place, time, and situation. Attention is normal. She recalled 3/3 words after 5 minutes. Long-term memory is intact. Abstract thinking is concrete (gave literal answers only).”
• “Patient is drowsy but arousable. He is oriented only to person. He does not know the date or where he is. Short-term memory is poor: 0/3 words after 3 minutes.”

Quick Cognitive Screening (Mini-Cog):

Task	Normal	Abnormal
Ask patient to remember 3 words	Repeats all 3	Misses 1 or more
Ask patient to draw a clock showing 11:10	Draws circle, numbers in order, hands correct	Missing numbers, wrong time
Ask patient to recall the 3 words	Recalls all 3	Recalls 0-2

Part 9: Insight and Judgment (Do They Understand Their Illness?)

Insight means: Does the patient know they are sick? Do they understand they need help? Judgment means: Can they make safe decisions? Will they walk into traffic? Will they give money to a stranger who lies to them?

Checklist for Insight:

• Excellent: Knows they have an illness. Understands treatment helps.
• Partial: Knows something is wrong but blames others. “I am sad because my boss hates me.”
• Poor: Thinks nothing is wrong. “I do not need medicine. I am fine.”

Checklist for Judgment:

• Good: Makes safe choices. Can predict what will happen.
• Fair: Makes some poor choices but can learn.
• Poor: Makes dangerous choices. Cannot predict outcomes.

Examples of what to write:

• “Insight is good. Patient admits she has depression and says medication helps. Judgment is good. She says she would call a friend if she felt suicidal.”
• “Insight is poor. Patient says ‘There is nothing wrong with me. The voices are real people.’ Judgment is poor. He says he would walk home in a snowstorm without a coat.”
• “Insight is partial. Patient knows he is anxious but thinks it is only because of his job. Judgment is fair.”

Simple Test of Judgment: Ask “What would you do if you saw smoke coming from your house?” A good answer: “Call 911 and leave.” A poor answer: “Ignore it” or “Go back to sleep.”

Full MSE Cheat Sheet (Checklist)

Print this page. Keep it in your pocket.

1. Appearance

• Grooming/Hygiene
• Dress
• Body type
• Physical signs (scars, shakes)

2. Behavior/Attitude

• Eye contact
• Motor activity (calm, restless, slow)
• Facial expression
• Attitude (cooperative, hostile)

3. Speech

• Rate (fast, normal, slow)
• Volume
• Clarity
• Amount

4. Mood (Patient says) _____________
5. Affect (You see)

• Range (full, restricted, flat)
• Stability (stable, labile)
• Congruence (matches mood? Y/N)

6. Thought Process

• Logical
• Tangential
• Circumstantial
• Flight of ideas
• Loosening of associations
• Blocking

7. Thought Content

• Delusions (type: _____)
• Obsessions
• Phobias
• Suicidal thoughts (plan? means?)
• Homicidal thoughts

8. Perceptions

• Hallucinations (auditory, visual, tactile, olfactory)
• Illusions
• Depersonalization/Derealization

9. Cognition

• Alertness (awake, drowsy)
• Orientation (person, place, time, situation)
• Attention (spell WORLD backwards)
• Memory (immediate, short-term, long-term)
• Abstract thinking

10. Insight/Judgment

• Insight (good, partial, poor)
• Judgment (good, fair, poor)

How to Write an MSE Summary (Example)

Here is how you put it all together in a patient’s chart. Keep it short but complete.

Example 1: Normal MSE (for a healthy person)

The patient is a 45-year-old female who appears her stated age. She is clean, well-groomed, and dressed appropriately. She makes good eye contact and is cooperative. Her speech is normal in rate, volume, and clarity. She reports her mood as “good.” Her affect is full range and congruent. Thought process is logical and goal-directed. There are no delusions, obsessions, or phobias. She denies suicidal or homicidal thoughts. She denies hallucinations. She is alert and oriented to person, place, time, and situation. Attention and memory are intact. Insight and judgment are good.

Example 2: Abnormal MSE (for a patient with psychosis)

The patient is a 28-year-old male who appears younger than his stated age. He is unshaven and wearing a torn t-shirt and no shoes. He paces back and forth during the interview. He refuses eye contact and is guarded. Speech is rapid and difficult to interrupt. He reports mood as “angry.” Affect is irritable and labile. Thought process shows loosening of associations. Thought content includes paranoid delusions that the CIA is watching him. He denies suicidal thoughts but admits to wanting to hurt “the agents.” He reports auditory hallucinations of voices telling him to run. He is alert but oriented only to person and place (not time). Memory is poor. Insight and judgment are poor. He does not believe he is ill.

Final Tips

1. The MSE takes practice. Do not worry if it feels hard at first. Use this cheat sheet every day.
2. Be kind. The MSE can feel like an interrogation. Explain what you are doing: “I am going to ask you some standard questions to understand how you are feeling.”
3. Safety first. Always ask about suicide and violence. Document your answers clearly.
4. Compare to baseline. If you know the patient, ask family what is normal for them.
5. Use simple words with patients. Do not say “I am assessing your affect.” Say “I am just watching how you look when you talk.”

You now have a complete guide. Keep this cheat sheet with you. You will be doing great MSEs in no time. Go help your patients with confidence.

for clinicians · HIPAA-ready

Spend more time with patients, not paperwork.

Skriber transforms ambient speech into accurate SOAP notes — finished before your next session.

Start Free

No credit card required.