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Mental State Examination

Structured mental status assessment and tracking

The Mental State Examination (MSE) section allows you to record and track standardized mental status assessments for clients. Each MSE captures a comprehensive snapshot of the client's mental state at a specific point in time.

Accessing MSE Records​

From any client record page, click "Mental State Examination" in the left navigation sidebar to jump to this section.

Header Display​

The section title shows the total count of MSE records:

Example: "Mental State Examination (12)" indicates 12 total MSE assessments for this client

Header Actions​

Insights Button​

The insights icon (chart icon) opens the MSE Tracker Dialog:

Purpose: Visualize changes in MSE assessments over time

Displays:

  • Trends across multiple assessments
  • Comparison between current and previous MSEs
  • Patterns in specific MSE components
  • Changes that may indicate progress or decline

Click the insights button to open the tracker dialog with visual analysis.

Add Button​

The "+" button opens the MSE Dialog to record a new assessment:

  1. Click the "+" button
  2. MSE dialog opens with all assessment fields
  3. Complete each section of the MSE
  4. Click save to record
  5. New MSE appears at top of list

The add button is disabled if:

  • You don't have note owner permissions
  • The client has exceeded usage limits

Expand/Collapse Button​

Controls display of MSE records:

Collapsed: Shows only the most recent (latest) MSE

Expanded: Displays all MSE records in chronological order

The button appears only when more than one MSE record exists.

MSE Structure​

Each Mental State Examination includes the following standardized components:

Appearance​

Physical presentation and grooming observations:

  • Clothing and hygiene
  • Physical build and stature
  • Distinguishing features
  • Overall presentation

Behavior​

Motor activity and observable behaviors:

  • Psychomotor activity level
  • Eye contact
  • Mannerisms or tics
  • Level of cooperation
  • Unusual movements

Mood​

Client's subjective description of emotional state:

  • Client's own words about how they feel
  • Duration of mood
  • Severity
  • Appropriateness to situation

Affect​

Clinician's observation of emotional expression:

  • Range (full, restricted, blunted, flat)
  • Appropriateness to content
  • Stability (labile or stable)
  • Intensity
  • Congruence with mood

Thought Content​

Themes and preoccupations in client's thinking:

  • Suicidal or homicidal ideation
  • Delusions or obsessions
  • Preoccupations or worries
  • Overvalued ideas
  • Specific concerns or themes

Thought Process​

Organization and flow of thoughts:

  • Logical or illogical
  • Goal-directed or tangential
  • Circumstantial or loose associations
  • Flight of ideas or thought blocking
  • Racing thoughts or rumination

Perception​

Presence of hallucinations or illusions:

  • Auditory hallucinations
  • Visual hallucinations
  • Other sensory disturbances
  • Depersonalization or derealization
  • Illusions

Cognition​

Mental functioning assessment:

  • Orientation (person, place, time, situation)
  • Attention and concentration
  • Memory (immediate, recent, remote)
  • Calculations
  • Abstract thinking

Insight​

Client's understanding of their condition:

  • Awareness of having a problem
  • Understanding of cause
  • Recognition of need for treatment
  • Acceptance of diagnosis
  • Realistic self-appraisal

Judgment​

Decision-making and reasoning capacity:

  • Ability to make sound decisions
  • Understanding of consequences
  • Problem-solving capacity
  • Reality testing
  • Social judgment

Risk Assessment​

Safety evaluation:

  • Suicidal ideation, plan, intent, means
  • Homicidal thoughts
  • Self-harm behaviors
  • Danger to others
  • Protective factors

Recording an MSE​

Opening the Dialog​

Click the "+" button to open the MSE Dialog with all assessment fields.

Completing the Assessment​

  1. Systematically assess each MSE component
  2. Document observations in each field
  3. Be specific and objective in descriptions
  4. Note any changes from previous assessments
  5. Complete risk assessment thoroughly
  6. Click save to record the MSE

After Recording​

New MSE record:

  • Appears at top of list as the latest assessment
  • Shows timestamp of assessment
  • Can be edited or deleted
  • Included in insights tracking

Display and Organization​

Latest MSE​

The most recent MSE always displays first in full detail:

Shows:

  • All MSE components
  • Timestamp of assessment
  • Edit and delete actions
  • Complete assessment details

Previous MSEs​

Older MSE records appear collapsed (when expanded):

Behavior:

  • Sorted by timestamp (newest to oldest)
  • Each MSE shows date and summary
  • Click to view full details
  • Edit or delete actions available

Empty State​

When no MSE records exist:

Message displayed: "You have not added any mental state examination for [Client Name] yet."

Action: Click "+" to create first MSE

Editing MSE Records​

Edit Action​

Click the edit icon on any MSE card:

  1. MSE dialog opens with pre-filled data
  2. Modify any assessment fields
  3. Click save to update
  4. Changes reflect immediately in list

Edit Permissions​

Editing available if:

  • You are the note owner
  • Usage limits not exceeded
  • You have edit permissions

Deleting MSE Records​

Delete Action​

Click the delete icon on any MSE card:

  1. Record removed from list
  2. No longer appears in insights tracking
  3. Permanent deletion (cannot be recovered)

Only note owners can delete MSE records.

MSE Insights Tracker​

Purpose​

The insights tracker provides visual analysis of MSE changes over time.

Opening the Tracker​

Click the insights button (chart icon) in the section header.

Tracker Features​

Displays:

  • Timeline of all MSE assessments
  • Component-by-component comparison
  • Trends in specific areas
  • Notable changes or patterns
  • Visual indicators of improvement or decline

Use for:

  • Identifying patterns across sessions
  • Documenting treatment progress
  • Recognizing early warning signs
  • Supporting clinical decision-making
  • Insurance or legal documentation

Permissions​

Note Owner​

Full access to:

  • Create new MSE assessments
  • Edit existing MSEs
  • Delete MSE records
  • View insights tracker

Team Members​

Limited to:

  • View MSE records only
  • View insights tracker
  • Cannot create, edit, or delete

Usage Limit Exceeded​

When limits exceeded:

  • Cannot create new MSEs
  • Cannot edit existing MSEs
  • Can view all assessments
  • Can view insights tracker
  • Red banner indicates restriction

Best Practices​

Assessment Frequency​

Conduct MSE assessments:

  • At intake (baseline assessment)
  • Every 3-6 months for stable clients
  • More frequently during acute episodes
  • When significant changes occur
  • Before diagnostic decisions
  • As required by treatment setting

Documentation Standards​

Record MSE findings:

  • Use objective, observable language
  • Avoid interpretations without evidence
  • Be specific rather than general
  • Document exact quotes when relevant
  • Note comparison to previous MSEs
  • Complete all sections thoroughly

Risk Assessment​

Always document risk thoroughly:

  • Specific suicidal or homicidal thoughts
  • Plans, intent, and means
  • Protective factors
  • Safety planning implemented
  • Level of supervision needed
  • Emergency contacts notified

Using Insights​

Leverage the insights tracker to:

  • Identify subtle changes over time
  • Support treatment modifications
  • Document medication effects
  • Recognize decompensation early
  • Validate treatment effectiveness

Integration with Other Sections​

Treatment Plan​

Use MSE findings to:

  • Inform treatment goal selection
  • Guide intervention choices
  • Monitor goal progress
  • Adjust treatment strategies

Session Notes​

Reference MSE in notes:

  • Mention significant findings
  • Note changes from previous MSE
  • Document clinical impressions
  • Support diagnostic formulations

Risk Management​

MSE informs safety planning:

  • Current risk level
  • Need for increased monitoring
  • Hospitalization considerations
  • Family notifications

Clinical Considerations​

Timing​

Conduct MSE:

  • Early in session for baseline
  • After client has settled in
  • When mental status concerns arise
  • Systematically through session
  • Before ending high-risk sessions

Objectivity​

Maintain objectivity by:

  • Using descriptive rather than judgmental language
  • Separating observations from interpretations
  • Documenting specific behaviors
  • Avoiding assumptions
  • Using standardized terminology

Changes Over Time​

Track changes by:

  • Comparing to previous MSEs
  • Noting subtle shifts
  • Documenting improvements
  • Recognizing decline early
  • Correlating with life events or treatment changes

Next Steps​

Learn about related assessment and documentation:

Pro Tip

Use the insights tracker before treatment planning sessions to identify MSE patterns that should inform therapeutic goals. For example, persistent cognitive issues might indicate a need for psychoeducation goals, while consistent risk factors require safety-focused interventions.

Last updated on by Anurag Mandal