Mental Status Exam

Appearance:

Well-groomed

Disheveled / Unkempt

Age-appropriate dress

Unusual / Bizarre appearance

Poor hygiene

Behavior:

Cooperative

Guarded / Defensive

Agitated / Restless

Withdrawn / Passive

Good eye contact

Poor eye contact

Psychomotor retardation

Psychomotor agitation

Speech:

Normal rate, rhythm, volume

Pressured / Rapid

Slow / Soft / Monotone

Loud / Increased volume

Poverty of speech

Mood (client-reported):

Euthymic

Depressed / Sad

Anxious / Worried

Irritable / Angry

Euphoric / Elevated

Hopeless

Affect (clinician-observed):

Full range / Congruent

Restricted / Constricted

Flat / Blunted

Labile

Incongruent with stated mood

Thought Process:

Linear and goal-directed

Circumstantial

Tangential

Loose associations

Flight of ideas

Perseverative

Thought Content:

No SI / No HI

Passive SI present

Active SI — see C-SSRS below

HI present — see risk documentation

Delusions (paranoid / grandiose / somatic / other)

Obsessions / Compulsions

Phobias

Perception:

No perceptual disturbances

Auditory hallucinations (AH)

Visual hallucinations (VH)

Illusions / Derealization / Depersonalization

Cognition:

Alert and oriented ×4

Attention intact

Memory intact (immediate / recent / remote)

Impaired — describe:

Cognitive screen (MoCA / MMSE) — score:

Insight / Judgment:

Insight: Good

Insight: Fair

Insight: Limited / Poor

Judgment: Good

Judgment: Fair

Judgment: Poor

Abnormal Findings

Notable findings:

Severity / Impairment:

Comparison to baseline:

Risk / Safety Review

1. Ideation Level

0 — None 1 — Wish Dead 2 — Nonspecific Thoughts 3 — With Method 4 — With Intent 5 — With Plan

1. Actual Attempt

Self-Injurious Behavior with Intent to Die

2. Interrupted Attempt

3. Aborted/Self-Interrupted Attempt

4. Preparatory Acts or Behaviors

5. Non-Suicidal Self-Injury (NSSI)

Most Recent Behavior

yyyy-mm-dd

Lethality (0-10)

Clinician Risk Override

No Override

Summary & Next Steps

Follow-up assessment needed:

Yes — specify:

Referral indicated:

Yes — specify:

Notes:

Plan and Follow-Up

Plan area	Details
Next visit
Orders & referrals
Patient instructions
Monitoring & safety

Mental Status Exam

Abnormal Findings

Risk / Safety Review

C-SSRS

Suicidal Ideation Severity ⓘ

Suicidal behavior (lifetime; most recent date below)

Risk Details

Summary & Next Steps

Plan and Follow-Up

Counseling - MSE Builder

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