Mental state assessment (MSE) template

How to fill it in

1. Copy the blank template into your record system.
2. Fill in what was discussed or assessed. Keep uncertainty visible, and use [not stated] where required information is missing.
3. Check the details and any gaps before saving or sharing. The clinician must explicitly confirm any generated content.

A mental state examination (MSE), also called a mental state assessment, captures how a person presents at a particular time. A helpful record lets the next reader follow what the person described, what the clinician observed and what could not be assessed. Keep the wider history, diagnostic formulation and management plan in the accompanying consult note.

The vocabulary below can help you describe findings already assessed. Choose words that fit the observation, rather than using the lists as default findings. In this standalone template, an unaddressed domain stays [not stated]. If it was declined or could not be assessed, record that specific limit.

Assessment context

Start with when, where and how the assessment took place, and who supplied information. Include an interpreter, information from others or communication difficulties where relevant. Make current findings clear alongside any earlier history.

“In person”, “telephone”, “person’s account” and “limited by connection quality” are useful details. A previous MSE remains an earlier assessment, even when copied into today’s record.

Appearance

Describe relevant visible details such as clothing, grooming and posture. “Clothing visibly soiled” or “posture slumped” tells the reader what was observed. Terms such as “neatly groomed” or “unkempt” need support from the actual observation; keep descriptions respectful of identity and culture.

A telephone contact cannot establish visual appearance. Say when it could not be assessed, or identify who supplied a description.

Behaviour

Describe engagement, movements and interaction during the encounter. Words such as “engages readily”, “hesitant to answer”, “restless”, “pacing”, “motor activity slowed” or “agitated” can help when supported by what happened.

A concrete detail often helps more than a label: “stood and walked around twice” explains the observation. Silence, eye contact or declining a question does not by itself establish a diagnosis or intention.

Speech

Describe the rate, volume, amount, spontaneity and fluency assessed. Useful words include “conversational rate”, “slow”, “rapid”, “soft”, “loud” and “answers after prompting”. Note an interpreter or communication aid where it affects the assessment.

Use the clinician’s description and its limits. An accent is not an abnormal finding.

Mood

Use the person’s description of how they feel, with timing where discussed. A short quotation often keeps their meaning well. “Low”, “anxious”, “irritable”, “elevated” or “euthymic” may fit the assessment; none supplies a diagnosis on its own.

Reported mood and observed affect have separate places in the record. If mood was not discussed, leave it unknown rather than deriving it from an expression, voice or presenting concern.

Affect

Describe the emotional expression the clinician observed, its range and how it related to the discussion. Useful terms include “reactive”, “restricted”, “blunted”, “flat”, “labile”, “congruent” and “incongruent”, with an observation to explain them.

“Restricted” describes a limited range; “blunted” describes reduced expression; “flat” describes very little observable expression; “labile” describes marked shifts. Keep those differences clear. On a telephone call, state the limits of visual assessment. A person’s report of feeling “flat” belongs under mood unless affect was separately assessed and described.

Thought form

Use the clinician’s description of how ideas connected in the conversation. Vocabulary includes “coherent”, “goal-directed”, “circumstantial”, “tangential”, “thought blocking”, “flight of ideas”, “loose associations” and “perseverative”. A short attributed example can help explain a term.

Keep the organisation of thought separate from its subject matter. Preserve uncertainty. A transcription error, language difference or unfamiliar expression must not become a thought-disorder finding.

Thought content

Include the themes, worries, intrusive thoughts or beliefs explored, using the person’s account. Where discussed, include conviction, distress and cultural context. Phrases such as “preoccupied with”, “rumination”, “intrusive thought” or “overvalued idea” may fit the clinician’s assessment.

Use a delusion label only when the clinician stated it; an unusual belief alone is not enough. Keep thoughts of harm and their assessment visible in the risk section. An undiscussed area must not become “no abnormal content”.

Perception

Describe the experiences discussed, the sense involved, their timing and the person’s words. Terms such as “auditory experience”, “visual experience”, “hallucination”, “illusion”, “depersonalisation” and “derealisation” belong only where used in the assessment.

Make it clear whether an experience was reported, present now, indirectly observed or denied when asked. Include a voice’s content or commands if discussed. No mention of voices is not a denial, and a glance or pause does not establish a perceptual disturbance.

Cognition

Describe the alertness, orientation, attention, concentration or memory assessed, with the evidence obtained. “Alert”, “orientation established to time and place”, “attention not tested” or “needed repeated redirection” can make the scope clear.

If a separate tool was used, name it and keep the recorded result and limitations. This template does not administer a test or calculate a score. Following a conversation alone does not establish “cognition intact”.

Insight

Describe the person’s understanding of their experiences and the clinician’s assessment of it. What change do they recognise? What explanation do they give? Record answers actually discussed and anything still uncertain.

“Recognises a change”, “partial understanding” or “does not share the clinician’s explanation” is more useful with a concrete example. Agreement, treatment acceptance or disagreement alone does not establish “good” or “poor” insight.

Judgement

Include the decision or practical situation explored, the clinician’s conclusion and its limits. Phrases such as “decision-making not assessed”, “weighs the stated options” or “difficulty considering the stated consequences” need support from the encounter.

One choice, attendance or cooperation does not establish sound judgement overall. Legal capacity requires its own assessment; completing this field does not establish it.

Risk and safety assessment

Set out the areas explored, the person’s answers, relevant sources and the clinician’s assessment. Include agreed actions. Where discussed, keep thoughts, intent, plans, access to means, previous events, supports and safeguarding concerns distinct.

“Denies current suicidal thoughts when asked”, “not assessed” and “assessment incomplete” mean different things. A negative answer in one area does not establish overall safety. Include a risk level, urgency or safety plan only when the clinician stated it, and keep unfinished assessment clear.

Common omissions

Check the time and contact method, who observed each finding, mood versus affect, thought form versus content, and current versus earlier experiences. Keep remote limits, untested cognition and unfinished risk assessment visible. Using a descriptor does not show that an examination took place.

Review before saving

Read each finding against the encounter. Check quotations, sources, explicit negative answers and limits. Remove unsupported normal findings or interpretations. Review [not stated] gaps with the clinician; add only information obtained through their assessment. The record remains a draft until the clinician explicitly confirms it.