Counselors Template

Mental State Exam (MSE) Notes

A professional Counselors template for healthcare professionals.

About this template

The Mental State Exam (MSE) Notes template is an essential tool for counselors and mental health professionals to document a comprehensive assessment of a patient's psychological functioning. This template guides clinicians through evaluating key areas such as appearance, behavior, speech, mood, affect, thought processes, perception, cognition, insight, and judgment. By using this structured format, counselors can ensure a thorough and consistent examination, aiding in the diagnosis and treatment planning for mental health conditions. This template is particularly useful for creating detailed mental health progress notes and psychiatric evaluations.

Preview template

Patient Information: - John Doe - 45 years old - Male - 1 November 2024 Appearance: - The patient appeared disheveled, with unkempt hair and wrinkled clothing. Hygiene was poor, and there were noticeable signs of self-neglect. Behaviour: - The patient exhibited restless motor activity, frequently shifting in his seat. Eye contact was minimal, and he appeared uncooperative at times. Speech: - Speech was rapid and pressured, with occasional slurring noted. Mood: - The patient reported feeling 'down' and 'hopeless'. - Observed mood was congruent with the reported feelings of depression. Affect: - Affect was flat and restricted, with little variation in emotional expression. - The affect was congruent with the reported mood of depression. Thought: - Thought process was disorganized, with frequent tangential thinking. The patient expressed delusional beliefs about being monitored by unknown entities. Perception: - The patient reported auditory hallucinations, describing voices that were critical and derogatory. Cognition: - The patient was oriented to person but disoriented to time and place. Memory recall was impaired, and attention was fleeting. Insight: - The patient demonstrated limited insight into his condition, expressing skepticism about the need for treatment. Judgment: - Judgment was impaired, as evidenced by the patient's inability to recognize the potential consequences of his actions, such as neglecting personal hygiene. Counselor Information: - Dr. Thomas Kelly - Licensed Professional Counselor - 1 November 2024

Patient Information: - [patient name] (only include patient name if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) - [patient age] (only include patient age if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) - [patient gender] (only include patient gender if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) - [date of assessment] (only include date of assessment if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Appearance: - [describe general appearance, grooming, clothing, and hygiene as specific as possible] (only include describe general appearance if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) - [specifically note any unusual physical characteristics or signs of self-neglect] (only include note any distinguishing features if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Behaviour: - [describe motor activity, eye contact, and level of cooperation as specific as possible] (only include describe general behaviour if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) - [specifically note any unusual movements or mannerisms, signs of agitation or restlessness] (only include note any unusual movements or mannerisms if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Speech: - [describe speech rate, volume, fluency, and tone as specific as possible] (only include describe speech rate, volume, and tone if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) - [specifically note any abnormalities such as slurring, rapid speech, or long pauses] (only include note any speech abnormalities if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Mood: - [describe patient's self-reported mood as specific as possible] (only include describe patient's self-reported mood if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) - [specifically note any observed mood] (only include note any observed mood if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Affect: - [describe observed emotional state, range and appropriateness of affect as specific as possible] (only include describe range and appropriateness of affect if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) - [specifically note if the affect is congruent with the reported mood] (only include note any incongruence with mood if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Thought: - [describe thought process and content, including any delusions or obsessions, as specific as possible] (only include describe thought process if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) - [specifically note any thought content abnormalities, signs of disorganized thinking or unusual beliefs] (only include note any thought content abnormalities if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Perception: - [describe any hallucinations, perceptual disturbances, or illusions, as specific as possible] (only include describe any hallucinations or illusions if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) - [specifically note any derealization or depersonalization, especially related to all sensory modalities such as visual, auditory, tactile, etc.] (only include note any derealization or depersonalization if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Cognition: - [describe orientation to time, place, and person, also memory, attention, and concentration, as specific as possible] (only include describe orientation to time, place, and person if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) - [specifically note any orientation, memory, attention, or concentration issues] (only include note any memory or attention issues if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Insight: - [describe patient's awareness of their condition and need for treatment as specific as possible] (only include describe level of insight into condition if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) - [specifically note any discrepancies in insight, especially if they don't understand their mental health issues] (only include note any discrepancies in insight if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Judgment: - [describe judgment, decision-making ability, and understanding of consequences in hypothetical situations as specific as possible] (only include describe judgment in hypothetical situations if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) - [specifically note any observed judgment issues, especially related to their ability to make safe and responsible decisions] (only include note any observed judgment issues if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Counselor Information: - [counselor name] (only include counselor name if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) - [counselor credentials] (only include counselor credentials if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) - [date of report] (only include date of report if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information include in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.) the transcript.)

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