Mental State Examination (MSE) Template: AU Examples

What is a Mental State Examination Template?

A mental state examination (MSE) is a vital part of most psychiatric interviews. By assessing and commenting on the 10 sections of an MSE - appearance, behaviour, speech, mood, affect, thought, perception, cognition, insight and judgment - the mental health clinician documents a thorough evaluation of a patient's psychiatric functioning and emotional health.

Many clinicians use a mental state examination template to streamline the process and ensure that no important information is missed during the interview.

In this article, we explore common challenges with conducting a mental state examination and the advantages of using a high-quality template. We also walk through the 10 steps of the mental state exam and how an AI-enabled MSE template can make the process faster and easier.

The Importance of MSE Templates in Australian Mental Health Care Delivery

In Australia, a mental state examination rarely stays with one clinician. It follows the patient across an unevenly distributed system, from a GP or emergency department to a community team, an inpatient unit, or a psychiatrist reached by telehealth in a regional town.

With about 4,500 psychiatrists nationally and 85% of them working in major cities, much of a person's mental health care is shared, handed over, and picked up by someone who was not in the room. A consistent, well-structured MSE is what keeps that assessment legible to whoever reads it next.

Under each state and territory's Mental Health Act, the MSE is a clinical basis for decisions about involuntary assessment and treatment, and those decisions are later examined by a Mental Health Tribunal. An examination that is complete, observation-based, and clearly recorded holds up to that review in a way a rushed or partial note does not.

Structure also supports the measurement Australian services are built on. Public mental health care reports standardised outcomes such as HoNOS through the national NOCC collection, and a disciplined MSE feeds those measures more accurately.

It matters clinically, too: in a country this culturally diverse, where people from culturally and linguistically diverse backgrounds face higher rates of involuntary care, a shared framework helps reduce the variability and cultural blind spots that can slip into an unstructured assessment and supports culturally safe care for Aboriginal and Torres Strait Islander patients.

A template is how clinicians hold that standard in place, patient after patient and service to service.

Common Challenges with Mental State Exams in Australia

Most challenges around completing an MSE stem from a combination of three issues:

1. MSEs are usually long documents that summarise inherently complex assessments.
2. The MSE forms the basis for risk management, so contents may be subject to scrutiny, particularly in cases involving involuntary treatment and detention.
3. Psychiatrists and mental health clinicians are usually complete MSEs under significant time pressure.

As a result, many clinicians, particularly trainee or junior psychiatrists, find writing MSEs stressful. The document must be thorough, complete and accurate. At the same time, there is always another patient to see or a crisis to attend to, adding time pressure to an already demanding task.

Using a complete mental state examination template is one of the most effective ways to make the process faster, more accurate, and less mentally taxing.

Advantages of Using a Good MSE Template

Completing MSEs with a high-quality mental state examination template has several benefits:

Reduced cognitive load

Rather than remembering every aspect of the MSE, the clinician can refer to the template to guide the interview. This frees up mental energy to focus on patient observations and clinical reasoning.

Improved efficiency and completeness

An MSE template's structure helps keep clinical interviews focused on pertinent issues. This can reduce overall interview time and prevent accidental omissions that require follow-up.

Stronger medicolegal documentation

MSE templates are known to improve the quality of junior psychiatrists' documentation. In the event of an audit or legal review, detailed and organised observations demonstrate thorough clinical assessment and sound professional practice.

Enhanced patient engagement

Splitting attention between tracking the MSE process and engaging with the patient is difficult. A template allows clinicians to stay more present with the patient, which often leads to better engagement.

Mental health clinicians in Australia are increasingly turning to AI-enabled platforms like Heidi to build on the benefits of clinical note templates. By handling documentation across progress notes, referral letters and MSEs, Heidi helps mental health clinicians cut daily documentation time by an average of 2.34 hours per day.

For a first-hand account, read how Dr. Tony Fernando used Heidi to reduce his daily documentation time from 2 to 3 hours down to 30 to 60 minutes.

How to Write a Mental State Examination

Every MSE should address all 10 sections listed below. The clinician may deviate from the order of topics during the interview. For consistency and ease of reading, it is recommended to maintain the original sequence in the final document.

Below is a brief overview of each section with an example sentence. Where no concern or abnormality is detected, make a brief statement reflecting your finding, such as "Cognition is intact with no abnormalities detected."

1. Appearance

Document the patient's physical presentation, including grooming, dress, hygiene, and any other notable characteristics. Include observations 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."

2. Behaviour

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 may be relevant, but remember that some level of distress in an inpatient setting, particularly involuntarily, is normal.

Example: "Patient demonstrates psychomotor agitation, frequently shifting in their chair and wringing their hands. Maintains intermittent eye contact and appears somewhat guarded."

3. Speech

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 the patient displayed some word-finding difficulties."

4. Mood

Record the patient's subjective description of their emotional state, ideally in their own words. Prompt the patient to use a numbered scale to describe symptom severity if needed. Use questions about interests, energy level, and motivation for a more thorough assessment. Note any diurnal variation in mood.

Example: "Patient describes mood as 'down and hopeless' over the past two weeks, rating it 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."

5. Affect

Note observations of the patient's emotional state expressed through non-verbal language. Consider type, range, reactivity, and appropriateness of affect.

Example: "Affect is restricted in range, predominantly low and congruent with reported depressed mood."

6. Thought

Assess and document thought stream, form, and content. Note any abnormalities in 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."

7. Perception

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.'"

8. Cognition

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 the ability to correctly spell 'WORLD' backwards."

9. Insight

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 whether they acknowledge the possibility of a mental health problem. Locus of control 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 the need for treatment. Understanding of health anxiety is somewhat limited, but the patient is open to exploring this further."

10. Judgment

Assess the patient's ability to make reasonable decisions and anticipate consequences. Include observations about recent decision-making and problem-solving ability. 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 plans of impulsive or risky behaviour."

With all the competing demands in psychiatric practice, producing a thorough MSE for every patient is time-consuming. Clinicians are now using AI-enabled templates to write detailed, accurate MSEs in a fraction of the time.

Free Mental Health State Examination Templates