Mental State Examination (MSE) Template with Examples
LJ Acallar
Organic Content Specialist•April 17, 2026•10 min read•
Fact checked by Dr. Ben Condon
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Mental State Examination (MSE) Template
This Mental State Examination (MSE) template is designed for psychiatrists and other mental health clinicians to document a comprehensive assessment of a patient’s mental status. It covers all 10 areas of an MSE, prompting clinicians to evaluate and record a patient’s mental health systematically.
Includes all headings for documenting a structured MSE on a single editable template
Prompts under each section guide the clinician on what topics to address
Uses AI to organize information from the session into a completed MSE for the clinician to review
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, behavior, 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 make the process of conducting an MSE more streamlined and efficient. A template also serves to ensure no important information is missed during the interview.
In this article, we’ll explore common challenges with conducting a mental state examination and the advantages of using a high-quality template. Then, we go through what are the 10 steps of the mental state exam and how using an AI-enabled mental status examination template can make the process faster and easier.
Common Challenges with Mental State Exams
Most of the challenges around completing an MSE stem from a combination of three issues:
MSEs are usually long documents that summarize inherently complex assessments.
The MSE forms the basis for risk management, so contents may be subject to scrutiny (e.g., cases of involuntary treatment and psychiatric holds).
Psychiatrists and mental health clinicians are usually completing MSEs under significant time pressures.
As a result of the above, many clinicians (particularly psychiatric residents or early-career psychiatrists) find writing MSEs somewhat stressful. On the one hand, the document must be thorough, complete and accurate. On the other hand, there’s always another patient to see or crisis to attend to, adding an element of time pressure to complete documentation.
Using a complete mental state examination template is one of the most effective ways to make the process of writing an MSE 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 to keep clinical interviews focused on pertinent issues. This can reduce overall interview time and prevent accidental omissions that the clinician needs to follow up afterward.
Stronger medicolegal documentation: MSE templates are known to improve the quality of documentation among psychiatric residents and early-career clinicians. In the event of a payer audit, malpractice review, or legal proceeding, detailed and organized documentation demonstrates thorough clinical assessment and sound professional practice.
Enhanced patient engagement - It’s exceedingly difficult to split attention between mentally tracking the process of an MSE and engaging with the patient. By using an MSE template, clinicians can focus more on the patient, which often leads to better engagement.
Mental health clinicians are increasingly turning to AI-enabled platforms like Heidi to enhance the benefits of clinical notes templates. By automating everything from progress notes to MSEs, Heidi helps mental health clinicians cut their daily documentation time by an average of 2.34 hours.
How to Write a Mental State Examination
Every MSE should address all of the 10 sections listed below. The clinician may deviate from the order of topics during the interview. However, for consistency and ease of reading, it’s recommended to maintain the original sequence in the final document.
Below is a brief overview of each section of an MSE with an example sentence for each. Where no concern or abnormality is detected in a particular area, make a brief statement reflecting your finding, such as, “Cognition is intact with no abnormalities detected.”
1. Appearance
This section documents the patient's physical presentation, including grooming, dress, hygiene and any other notable characteristics. Include a general description of physical appearance and 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. Behavior
Document the patient’s actions, movements and general demeanor. 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 at being in an inpatient setting, particularly involuntarily, is normal.
Example: “Patient demonstrates psychomotor agitation, frequently shifting in their chair and wringing 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 patient displayed some word finding difficulties.”
4. Mood
Record the patient’s subjective description of their emotional state (ideally in their own words). Can prompt the patient to use a numbered scale to describe the severity of symptoms if needed. Use questions about interests, energy level and motivation for increased depth of assessment. Note any changes in mood throughout the day (diurnal variation).
Example: “Patient describes mood as ‘down and hopeless’ over the past two weeks, rating it as 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 via non-verbal language. Consider types of emotions, range (constricted to labile), reactivity (blunted to flat to reactive) and appropriateness (congruence).
Example: “Affect is restricted in range, predominantly low and congruent with reported depressed mood.”
6. Thought
Assess and document thought stream (eg., poverty of thought or flight of ideas), form (logical or disordered) and content (obsessions, delusions, bizarre, etc). Note any abnormalities in the patient’s 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 derealization or depersonalization).
Example: “No evidence of hallucinations. Patient reports intermittent depersonalization, 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 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 if they acknowledge the possibility of a mental health problem. Locus of control (internal vs. external) may require comment and insight can be variable across domains.
Example: “Patient demonstrates good insight into their low mood, recognizing the impact on daily functioning and need for treatment. Understanding of health anxiety is somewhat limited but 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. Future 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 future plans of impulsive or risky behavior.”
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Mental State Examination (MSE) Template Example
You can download a copy of this document, or auto-fill it seamlessly with Heidi, your AI care partner.
With all the competing demands in psychiatric practice, producing a gold standard MSE for every patient is time consuming. More clinicians are now using AI-enabled templates to write detailed, accurate MSEs in a fraction of the time.
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Write Faster, More Accurate MSEs with Heidi
Heidi’s advanced AI medical scribe automates the process of writing an MSE. Press ‘Transcribe’ at the start of your session and conduct your interview as usual. When you’re done, the MSE is generated according to your template, ready to be reviewed. You can also use the same session to generate referral letters, risk summaries or patient-facing notes if needed.
Benefits of using Heidi’s AI-powered mental state examination templates include:
Improved accuracy - Heidi creates a full transcript of the session available so you can clarify or add details to the final document.
Faster documentation - Have a fully completed MSE ready to review within seconds of completing your interview.
Better patient care - With documentation handled automatically, you can focus entirely on your patient. Rapport and therapeutic alliance follow naturally.
Heidi is HIPAA-compliant and trusted by over 100,000 clinicians. Our Template Community contains field-tested templates created specifically for psychiatrists and mental health professionals.
This complete mental state examination template contains all 10 sections covered in an MSE, including patient information and counselor details. The template aims to make it easier for mental health professionals to comprehensively evaluate a patient’s psychological functioning, starting from appearance to judgment.
This MSE form template helps clinicians record a structured assessment of a patient’s mental state, including a suicidality and homicidality risk assessment. It guides observation across key areas such as appearance, behavior, speech, mood, and thought processes, ensuring no detail is missed.
The MMSE is a standardized cognitive screening tool that’s different from a mental state examination. It focuses specifically on cognitive function through a series of brief tests, assessing orientation, memory, attention, language and visuospatial skills.
MMSEs have been validated for specific use cases in geriatric medicine, for example in the serial monitoring of delirium or dementia over sequential visits. They’re typically scored out of 30 with a subset of relevant questions to cover most of the sections of a thorough MSE.
An MMSE template may be completed as part of a mental state examination or as a standalone assessment to identify individuals experiencing cognitive impairment.
