Sample Mini Mental Status example report

Mini Mental Status Examination

The following two fictional reports are samples for those individuals learning to conduct Mental Status Examinations and write MSE reports. They’re from the forthcoming 5th edition of Clinical Interviewing.

If you’d like to see a short video-clip MSE example, you can go to:

Mental Status Examination Reports

A good report is brief, clear, concise, and addresses the areas below:

1. Appearance

2. Behavior/psychomotor activity

3. Attitude toward examiner (interviewer)

4. Affect and mood

5. Speech and thought

6. Perceptual disturbances

7. Orientation and consciousness

8. Memory and intelligence

9. Reliability, judgment, and insight

The following reports are provided as samples.

Mental Status Report 1

Gary Sparrow, a 48-year-old white male, was disheveled and unkempt on presentation to the hospital emergency room. He was wearing dirty khaki pants, an unbuttoned golf shirt, and white shoes and appeared slightly younger than his stated age. During the interview, he was agitated and restless, frequently changing seats. He was impatient and sometimes rude in his interactions with this examiner. Mr. Sparrow reported that today was the best day of his life, because he had decided to join the professional golf circuit. His affect was labile, but appropriate to the content of his speech (i.e., he became tearful when reporting he had “bogeyed number 15”). His speech was loud, pressured, and overelaborative. He exhibited loosening of associations and flight of ideas; he intermittently and unpredictably shifted the topic of conversation from golf, to the mating habits of geese, to the likelihood of extraterrestrial life. Mr. Sparrow described grandiose delusions regarding his sexual and athletic performance. He reported auditory hallucinations (God had told him to quit his job and become a professional golfer) and was preoccupied with his athletic and sexual accomplishments. He was oriented to time and place, but claimed he was the illegitimate son of Jack Nicklaus. He denied suicidal and homicidal ideation. He refused to participate in intellectual- or memory-related portions of the examination. Mr. Sparrow was unreliable and exhibited poor judgment. Insight was absent.

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Download Mental Status Examination 2nd PDF
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