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Mental Status Exam Generator

Turn your observations into a complete mental status exam write-up, domain by domain.

Shorthand and abbreviations are fine.

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Mental status exam template and examples

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Mental status exam template. The standard domains, in order.

A mental status exam (MSE) records what you observe about a client’s appearance, behavior, mood, thinking and cognition at one point in time. Here is a blank MSE template with the standard domains, what to describe in each, and complete examples.

Blank template

MENTAL STATUS EXAMINATION

Client: ____________   Date: ____________   Setting: ____________

Appearance: (dress, grooming, hygiene, apparent age, notable features)
Behavior: (eye contact, psychomotor activity, mannerisms)
Attitude: (cooperative, guarded, irritable, hostile)
Speech: (rate, volume, tone, fluency)
Mood: (in the client's own words)
Affect: (range, intensity, congruence with mood)
Thought process: (linear, goal-directed, circumstantial, tangential, flight of ideas)
Thought content: (preoccupations, obsessions, delusions; suicidal and homicidal ideation as assessed)
Perception: (hallucinations, illusions)
Cognition: (orientation, attention, memory)
Insight: (good / fair / poor)
Judgment: (good / fair / poor)

Summary:

What goes in each section

Appearance and behavior
How the client looks and acts: dress, grooming, eye contact, psychomotor activity (calm, restless, slowed) and mannerisms.
Attitude and speech
How the client relates to you (cooperative, guarded, irritable) and how they speak: rate, volume, tone and fluency.
Mood and affect
Mood is what the client says they feel, best quoted. Affect is what you observe: its range, intensity and whether it matches the mood.
Thought process and content
How thoughts connect (linear, tangential, flight of ideas) and what the client thinks about, including suicidal and homicidal ideation as assessed.
Perception and cognition
Hallucinations or illusions, then orientation, attention, concentration and memory.
Insight and judgment
How well the client understands their situation and need for treatment, and the quality of their recent decisions.

Mental status exam examples. Shorthand in, a full write-up out.

Mental status exam example: depression

Outpatient intake, adult client.

Written from these notes

45M, intake. Unshaven, wrinkled clothes. Poor eye contact, psychomotor slowing. Cooperative. Speech slow, soft, long latency. Mood "empty". Affect constricted, dysphoric, congruent. TP linear. TC: hopelessness, guilt re job loss. Denies SI/HI when asked directly. Denies AH/VH. A&Ox4, concentration impaired (serial 7s stopped at 86). Insight fair, judgment fair.

Appearance: 45-year-old man, unshaven, in wrinkled clothing.

Behavior: Poor eye contact. Psychomotor slowing.

Attitude: Cooperative.

Speech: Slow and soft, with long response latency.

Mood: "Empty."

Affect: Constricted and dysphoric; congruent with stated mood.

Thought process: Linear and goal-directed.

Thought content: Themes of hopelessness and guilt about his recent job loss. Denies suicidal and homicidal ideation when asked directly.

Perception: Denies auditory and visual hallucinations.

Cognition: Alert and oriented to person, place, time and situation. Concentration impaired: stopped serial 7s at 86.

Insight: Fair.

Judgment: Fair.

Summary: Psychomotor slowing, soft and slowed speech, a constricted dysphoric affect, hopelessness, guilt and impaired concentration, a presentation consistent with a depressive episode. Denies suicidal and homicidal ideation on direct questioning. Consider a standardized depression measure such as the PHQ-9 and a structured suicide risk assessment as part of the intake.

Write yours with the generator

Every example describes a made-up client. The generator writes "Not assessed" for any domain your notes leave out and never records suicidal or homicidal ideation you did not document.

How to use the Mental Status Exam Generator

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  1. 01

    Fill in a few details

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    • Your observations
    • Format
    • Additional Instructions
  2. 02

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  3. 03

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Who it’s for. And what they make with it.

  • Psychiatric Evaluations

    Psychiatrists and psychiatric nurse practitioners turn interview shorthand into a complete, domain-by-domain MSE for the evaluation note.

  • Therapy Intakes

    Therapists and counselors document the mental status section of an intake in clinical language, with a short summary of what the findings suggest.

  • Inpatient and Emergency Settings

    Clinicians on busy units record a clear MSE quickly, with every domain they did not assess marked as such instead of filled in.

  • Social Workers and Case Managers

    Social workers add a professional mental status section to assessments and referrals, in the standard order other clinicians expect.

  • Students and Trainees

    Psychiatry, psychology, nursing and counseling students see how their observations map onto each MSE domain and learn the standard terms.

  • Telehealth Sessions

    Clinicians seeing clients by video write a narrative MSE from what they observed on screen, ready to paste into the record.

Take it further. Pair it with these tools.

Questions, answered.

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  • Is this tool HIPAA-compliant? Do you sign a BAA?

    Yes. Easy-Peasy.AI supports HIPAA-compliant use for clinical documentation and offers a Business Associate Agreement (BAA) for clinical accounts. You can review, sign, and download the BAA in your account settings: Manage your BAA.

  • What is a mental status exam?

    A mental status exam (MSE) is a structured record of how a client presents at one point in time: appearance, behavior, attitude, speech, mood, affect, thought process, thought content, perception, cognition, insight and judgment. It is part of most psychiatric evaluations and therapy intakes.

  • What are the components of a mental status exam?

    The usual domains, in order, are appearance, behavior, attitude, speech, mood, affect, thought process, thought content (including suicidal and homicidal ideation as assessed), perception, cognition (orientation, attention, memory), insight and judgment. The template on this page lists what to describe in each.

  • How do I write a mental status exam?

    Observe throughout the interview, then record each domain in order using descriptive, nonjudgmental terms. Quote the client’s own words for mood, describe affect by range and congruence, and end with a short summary of what the findings suggest. With the generator, you type or dictate your shorthand and it writes the full exam.

  • Will the generator invent findings?

    No. An MSE records what you observed, so the generator only writes up what your notes contain and marks any domain you didn’t cover as "Not assessed." It records suicidal and homicidal ideation exactly as you documented them and never fills them in. It adds professional wording, the standard order and a summary.

  • What is the difference between mood and affect?

    Mood is what the client tells you they feel, ideally in their own words ("empty", "stressed"). Affect is what you observe: its range (full, constricted, flat), intensity, stability and whether it matches the stated mood.

  • Can I get a narrative MSE instead of a list?

    Yes. Choose "Narrative paragraph" in the Format menu for a single paragraph, or keep "Domain by domain" for one line per domain. Both end with a summary.

  • Is there a free mental status exam template?

    Yes. This page has a blank MSE template and three complete examples. You can also generate an MSE here without an account (one a day), and a free account lets you keep using it within the Free plan’s monthly word allowance.

  • Who uses the mental status exam generator?

    Psychiatrists, psychiatric nurse practitioners, psychologists, therapists, counselors and social workers, and students learning to write an MSE. For the rest of the intake, see the Therapy Intake Generator.

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