How is the mental status exam performed and what are its main components?
The Mental status exam (MSE) is continuously performed throughout the encounter via observation of the patient.
It is not appropriate to document “unable to perform” a MSE as this means the patient was not observed.
If the patient does not participate in the encounter (due to disordered consciousness, refusal, or other reason), then that is an important observation to note as part of the MSE
The Main Components of the Mental Status Exam (MSE)
|Appearance and||Apparent age, body habitus, appropriateness of dress, grooming, hygiene, and distinguishing features|
|Behavior||Demeanor, posture/position, level of distress, degree of eye contact, attitude, psychomotor activity, gait, abnormal movements|
|Speech and||Coherence, rate, rhythm, volume, tone, and prosody|
|Language||Fluency, repetition, comprehension, naming|
|Mood and affect||Subjective and objective components of each, quality and range|
|Thought process and||Logicality, linearity, goal-directedness (inferred from speech)|
|Thought content||Suicidality, homicidality, delusions, obsessions, and usually also including perceptions: illusions and hallucinations)|
|Sensorium and||Level of consciousness and its stability|
|Cognition||Orientation, attention, concentration, intelligence, abstraction, executive function, construction (visuospatial)|
|Memory and||Registration and immediate, delayed, and autobiographical recall|
|Fund of knowledge||In relation to sociocultural and educational background|
|Insight and||Awareness of problems/behaviors including causes and ramifications; motivation to change|
|Judgment||Rationality of decisions made based on careful thought|
Note: A variety of component headings and subcomponents are used in clinical practice, and this list is a suggestion of components and is not intended to be exhaustive.
From American Psychiatric Association: Psychiatric evaluation of adults. 2nd ed. Am J Psychiatry 163: (6 Suppl):3–36, 2006.