Dictate anywhere on your screen, capture telehealth audio straight from the call,
and skip the second login.
LJ Acallar
Fact checked by Dr. Ben Condon
This mental state examination template is designed for psychiatrists and other mental health clinicians to document a comprehensive assessment of a patient’s mental status. It covers all 10 areas of an MSE, prompting clinicians to evaluate and record a patient’s mental health systematically.
A mental state examination (MSE) is a structured clinical assessment used in psychiatry to evaluate and document a patient's mental status across 10 defined areas: appearance, behaviour, speech, mood, affect, thought, perception, cognition, insight and judgment.
Many clinicians use a mental state examination template to make the process of conducting an MSE faster and more consistent. A template also helps ensure nothing gets missed, which matters in psychiatric interviews where a skipped section can affect clinical decisions. For clinicians in Ontario or British Columbia, a well-structured template can also simplify completing Form 1 or Schedule 1.
This article explores common challenges with conducting a mental state examination and the advantages of using a high-quality template, then walks through each of the 10 sections and how using an AI-enabled mental state examination template can make the process faster and easier.
Most of the challenges around completing an MSE stem from a combination of three issues:
Because of these reasons, many clinicians, particularly trainee or junior psychiatrists, find writing MSEs stressful. The document must be thorough, complete and accurate. At the same time, there’s always another patient to see or a crisis to attend to.
Using a complete mental state examination template is one of the most effective ways to write an MSE faster, more accurately and with less cognitive effort.
Completing MSEs with a high-quality mental state examination template has several benefits:
Mental health clinicians across Canada are increasingly turning to AI-enabled platforms like Heidi to strengthen the benefits of clinical notes templates. By automating everything from progress notes to referral letters to MSEs, Heidi is helping mental health clinicians work more sustainably. New data from the Ottawa Institute of Cognitive Behavioural Therapy show that clinicians reduced documentation time by 66 per cent, from 213 to 71 minutes per week. Clinician satisfaction with work-life balance also rose from 55 per cent to 83 per cent over four months.
For a personal account from a mental health clinician, you can read how Dr. Pete Kelly, clinical psychologist at OICBT, found that less time on after-hours documentation meant more focus, less burnout, and more presence with patients.
Every MSE should address all of the 10 sections listed below. The clinician may deviate from the order of topics during the interview, but for consistency and ease of reading, it’s recommended to maintain the original sequence in the final document.
Below is a brief overview of each section of an MSE with an example sentence for each. Where no concern or abnormality is detected in a particular area, make a brief statement reflecting your finding, such as, “Cognition is intact with no abnormalities detected.”
This section documents the patient's physical presentation, including grooming, dress, hygiene and any other notable characteristics. Take note of any unusual features, such as wearing a heavy jacket in summer or indicators of poor self-care.
Example: “Patient presents as a well-groomed, middle aged woman, dressed appropriately for the weather in clean, casual clothing.”
Document the patient's actions, movements and general demeanour. Note any unusual motor activity, interaction style and cooperation level. Observations about posture, eye contact and response to the interview setting are worth noting, but remember that some level of distress at being in an inpatient setting, particularly involuntarily, is normal. This is especially worth noting when the patient has been admitted involuntarily under a provincial mental health act, where the circumstances of admission carry their own weight.
Example: “Patient demonstrates psychomotor agitation, frequently shifting in their chair and wringing hands. Maintains intermittent eye contact and appears somewhat guarded.”
Describe physical characteristics of speech such as rate, volume, tone and rhythm. Note any unusual features or disturbances in speech patterns like pressure of speech, delayed responses or word-finding difficulties.
Example: “Speech is slow and quiet with increased latency of response. Normal rhythm but patient displayed some word finding difficulties.”
Include the patient’s subjective description of their emotional state, ideally in their own words. Prompt them to use a numbered scale to describe the severity of symptoms if needed. Use questions about interests, energy level and motivation for increased depth of assessment. Note any changes in mood throughout the day (diurnal variation).
Example: “Patient describes mood as ‘down and hopeless’ over the past two weeks, rating it as 4/10 (where 10 is the best they have ever felt). Low mood is persistent throughout the day with associated lethargy and lack of interest in previously pleasurable activities like gardening.”
Note observations of the patient’s emotional state expressed via non-verbal language. Consider types of emotions, range (constricted to labile), reactivity (blunted to flat to reactive) and appropriateness (congruence).
Example: “Affect is restricted in range, predominantly low and congruent with reported depressed mood.”
Assess and document thought stream (eg., poverty of thought or flight of ideas), form (logical or disordered) and content (obsessions, delusions, bizarre, etc). Note any abnormalities in the patient’s thought process and any concerns about thought content (such as suicidal or homicidal ideation).Example: “Thought process is logical and goal-directed. Rumination about health issues but no evidence of delusions or suicidal ideation.”
Record any abnormalities in sensory perception, including hallucinations of any sensory type and altered bodily experiences (such as derealisation or depersonalisation).
Example: “No evidence of hallucinations. Patient reports intermittent depersonalisation, stating, ‘When I get really worried about my health sometimes it feels like I’m outside of my body looking in - almost like it’s not me’”
Assess and document the patient’s level of consciousness, orientation, attention, concentration and memory. Include results from any formal cognitive testing undertaken during the interview.
Example: “Alert and oriented to person, place, time and situation. Demonstrates intact attention and concentration with ability to correctly spell ‘WORLD’ backwards”
Describe the patient’s understanding of their condition. Insight may be described as good, partial or poor. Note whether the patient can identify perceptual disturbances or high-risk thought content and if they acknowledge the possibility of a mental health problem. Locus of control (internal vs. external) may require comment and insight can be variable across domains.
Example: “Patient demonstrates good insight into their low mood, recognising the impact on daily functioning and need for treatment. Understanding of health anxiety is somewhat limited but open to exploring this further”
Assess the patient’s ability to make reasonable decisions and anticipate consequences. Include observations about recent decision making and problem solving ability. Future plans for addressing current challenges or stressors may also be relevant.
Example: “Judgment appears intact as evidenced by appropriate decision making regarding work and family responsibilities. No recent history or future plans of impulsive or risky behaviour.”
You can download a copy of this document, or auto-fill it seamlessly with Heidi, your AI care partner.
With all the competing demands in psychiatric practice, producing a ‘gold standard’ MSE for every patient is a very time consuming task. Forward-thinking clinicians are now using AI-enabled templates to write detailed, accurate and high quality MSEs in a fraction of the time of traditional methods.
With Heidi as your AI Care Partner, writing an MSE no longer has to follow the visit. Press ‘Transcribe’ at the start of your visit and conduct your interview as usual, safe in the knowledge that Heidi is working through the appointment with you. When you’re done, a completed MSE is ready for your review and approval, based on your template.
Benefits of using Heidi’s mental state examination templates include:
Heidi holds ISO 27001 and SOC 2 Type II certification, with privacy practices built to meet PIPEDA. Canadian clinicians have trusted it across 30.6 million patient interactions. The Template Community contains dozens of field tested templates created specifically for psychiatrists and mental health professionals.
This complete mental state examination template contains all 10 sections covered in an MSE, including patient information and counselor details. The template aims to make it easier for mental health professionals to comprehensively evaluate a patient’s psychological functioning, starting from appearance to judgment.
This MSE form template helps clinicians record a structured assessment of a patient’s mental state, including a suicidality and homicidality risk assessment. It guides observation across key areas such as appearance, behaviour, speech, mood, and thought processes, ensuring no detail is missed.
The MMSE is a standardised cognitive screening tool that’s different from a mental state examination. It focuses specifically on cognitive function through a series of brief tests, assessing orientation, memory, attention, language and visuospatial skills.
MMSEs have been validated for particular use cases in geriatric medicine, for example in the serial monitoring of delirium or dementia over sequential visits. They are scored out of 30, with questions designed to cover orientation, memory, attention, language and visuospatial skills.
An MMSE template may be completed as part of a mental state examination or as a standalone assessment to identify individuals experiencing cognitive impairment.