Mental Status Examination in Psychiatry

Example of Documentation

The MSE Interview Protocol below is Adapted from Clinical Interviewing (5th ed., 2014), published by John Wiley & Sons. For information on that title, go to:

Extended Mental Status Examination—Interview Protocol

This appendix contains a structured protocol for conducting a face-to-face (FtF), telephone, or videoconferencing mental status examination (MSE) interview. Some of the material is modified from the Mini-Mental State Examination (MMSE; Folstein, Folstein, & McHugh, 1975). We encourage you to modify the content or process in ways that work well within your particular setting.

You will notice this protocol includes space for writing notes and scoring whether clients responded accurately to some questions. However, we want to emphasize that this procedure is not standardized and has no normative sample. Consequently, we recommend that you use it qualitatively. Gathering data using this protocol will allow you to write a clear and concise mental status examination report. It also may support a much more extensive psychological or evaluation report. For a standardized process complete with norms, an alternative approach should be used (e.g., see the Mini-Mental State Exam, 2nd edition [MMSE-2]).

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