A mental status exam is an assessment of a patient's cognitive and behavioral functioning. It’s based on the clinician’s observations and the client's subjective descriptions. You might think of a mental status exam as a psychiatrist’s version of a physical exam. Behavioral health professionals use mental status exams to create a picture of how a person looks in the present moment — not all of the time.
Table of Contents
- What Are the Components of a Mental Status Exam?
- Why Are Mental Status Exams Important?
- When Are Mental Status Exams Performed?
- Who Uses Mental Status Exams?
- How Do I Write a Mental Status Exam?
- Mental Status Exam Checklist
- Mental Status Exam Example
- Claim Your Free Trial of ICANotes
What Are the Components of a Mental Status Exam?
In general, the components of a mental status exam include descriptions of the following:
- General behavior
- Speech and language
- Thought and perception
The exam may also include cognitive testing, depending on a client’s needs.
Why Are Mental Status Exams Important?
In combination with family and personal histories, the mental status exam forms the foundation for a psychiatric diagnosis.Clinicians can also use mental status exams for the following reasons:
- To determine if certain issues are improving or getting worse
- To identify areas that need attention from a specialist
- To offer a snapshot of a client at a specific point in time and provide that information to another provider
When Are Mental Status Exams Performed?
Mental status exams are often performed during the first one or two sessions with a client as part of the initial assessment and when reassessing their symptoms. It should be performed in person and not over the phone due to its visual elements. Mental status exams are especially useful in helping clinicians differentiate between various psychiatric and neurological disorders.
Typically, these exams are usedfor patients who have chronic, severe or acute symptoms. A mental status exam aims to capture dysfunction, though you can still use them to confirm ordinary function for clients.
As a behavioral health professional, you may choose to complete regular mental status exams to identify progress or on an as-needed basis throughout the treatment process. Completing a mental status exam at the end of treatment can highlight the differences in a client's presentation and illustrate their growth.
Who Uses Mental Status Exams?
Although mental status exams have been an assessment tool mainly used in clinical psychology, psychiatry and social work to examine patients with an altered mental status or evolving impairment of cognition, counselors and therapists can also use this type of exam as an informal way to gain information about a client’s cognitive and behavioral functioning. The counselor's findings can help them diagnose and treat a mental health disorder. Mental status exams also provide an excellent source of documentation to support a diagnosis.
How Do I Write a Mental Status Exam?
In private practice, you have the flexibility to create the sections you want to include in your mental status exam. When you are writing your mental status exam, review the typical sections, and identify which ones you believe will be useful to document during your intake assessments with clients.Keep in mind that some sections may be more or less relevant for specific clients.
To determine which portions to include in your mental status exam, consider your current clients. Would this apply to at least half of them? If so, it will likely be useful for you. If not, maybe you don't need to include it every time, and you can add it whenever necessary. You may also want to have an "other" section for topicsthat may come up during a mental status exam but do not fit in already established sections.
Mental Status Exam Checklist
To help you use a mental status exam as an assessment tool, we've created a cheat sheet. The following checklist is meant to be easy to read, so you can use it as a quick reference. Although you can customize a mental status exam to suit each client, you’ll generally want to focus on the categories in this checklist:
Appearance includes your observations of how a client looks initially and throughout the assessment. A client's appearance gives you an idea of their functioning level, their history and symptoms they're experiencing. Always look for signs of self-neglect and note anything unusual.
Hygiene and Grooming
Would you describe your client's hygiene and grooming as:
- Body odor
Is your client's clothing:
Is your client's makeup:
- No makeup
Does your client have any distinguishing features, such as:
Does your client appear:
- Older than their stated age
- Younger than their stated age
Is your client's habitus:
Does your client appear:
2. General Behavior
Describe how your client moves and behaves physically during the assessment. Always note if they are being hostile, uncooperative or have inappropriate impulses.
Isyour client's eye contact:
Does your client display:
- Normal activity
- Decreased activity
Does your client:
- Seem unsteady
- Use a cane, crutches or another device
Does your client display unusual movements in the jaw, face or tongue, such as:
- Tongue writhing
- Lip smacking
- Lip pursing
Cooperativeness and Attitude
Doesyour client exhibit an appropriate level of cooperation, or are they:
- Overly friendly
Does your client display any unusual or repetitive movements, such as:
3. Speech and Language
Consider how your client speaks and uses language. The amount a client speaks and how they talk can indicate a mental health issue such as depression or anxiety or a neurocognitive disorder.
Does your client speak clearly or have an:
Is your client's rate of speech:
- Delayed onset
Is your client's speech:
Is your client's speech:
Is your client:
Try to determine your client's emotional state by asking them how they feel and observing their facial expressions and body language.
Does your client say they feel:
Does your client seem to be:
Is your client's affect range:
- Broad: The client shows a normal range of emotions.
- Restricted: Theclient seems limited in expressing emotions.
- Flat: The client does not show any change in mood.
- Labile: The client's mood changes rapidly.
- Anhedonic: The client seems incapable of a pleasurable response.
Is your client's affect:
- Congruent to their mood
- Incongruent to their mood
5. Thought and Perception
Consider how your client's thoughts flow and connect and whether your client has a normal, linear thought process or if they go off-topic or make disorganized associations. Also, listen to what your client focuses on and find out if they're experiencing hallucinations. Always note hallucinations or the presence of delusions, and take appropriate action if a client expresses plans to carry out suicidal or homicidal ideation.
Would you describe your client's thought process as:
- Goal-directed: The client answers your questions and does not move onto other related topics.
- Impoverished: The client displays slow thinking and does not share many ideas.
- Rapid: The client expresses racing thoughts and rapid thinking.
- Illogical: The client does not make sense when they speak.
- Incoherent: The client's speech is disorganized, and there is no meaning to what they're saying.
- Distractible: The client cannot stay focused.
- Blocking: The client's thoughts are interrupted.
- Circumstantial: The client provides unnecessary detail but gets to the point eventually.
- Perseverative: The client shows a repetition of words, ideas or phrases.
- Tangential: The client moves from one related thought to the next but never reaches the point.
- Loose: The client shifts illogically between unrelated topics.
- Flight of ideas: The client quickly jumps from one idea to the next.
- Word salad: The client speaks words randomly.
Do your client's thoughts consist of:
- Suicidal ideation
- Homicidal ideation
- Grandiose, somatic, paranoid or other delusions
Is your client experiencing:
- No hallucinations
- Auditory hallucinations
- Visual hallucinations
- Tactile hallucinations
- Olfactory hallucinations
- Derealization, or feeling detached from the surroundings
- Depersonalization, or feeling separated from him- or herself
When evaluating a client's cognition, clinicians commonly assess the person's alertness or level of consciousness, orientation, attention, concentration and memory. If your client shows symptoms of a neurocognitive disorder, consider using additional tools such as the Mini-Mental State Examination or the Montreal Cognitive Assessment.
Is your client:
- In a stupor
Does your client know:
- Their name
- Their current location
- The date
- The time
To test your client's memory, you might ask them to do the following:
- Repeat three words immediately and again in five minutes.
- Sign their name while answering unrelated questions.
- Tell you their birthday, where they were born and their parents' names.
Does your client display:
- No impairment
- Short-term impairment
- Long-term impairment
Does your client's attention seem:
Describe your client's insight or their awareness of their situation or condition. Start by answering the following questions:
- How well does your client understand the reasons for their behavior?
- How well does your client appreciate how they contribute to a problem?
- Does your client recognize or acknowledge the severity of an issue?
- What do they perceive is the best way to address a problem?
Is your client's insight:
Consider if your client anticipates the consequences of their behavior and makes decisions to safeguard their well-being and that of others. Is their judgment:
Does your client show:
- Normal impulse control
- Impaired impulse control
Would you describe your client's motivation level as:
Consider your client's reliability and accuracy as they share details about their situation. Do you consider your client to be:
If part of your mental status exam includes assessing the client's living environment, you may want to describe their surroundings. Ask yourself the following:
- Have they made odd decisions, such as blocking doors or windows with furniture?
- Are there unusual decorations or wires that lead nowhere?
- Are they using any household objects inappropriately?
- Is their home extremely cluttered or dirty?
- Do they collect junk or garbage?
Mental Status Exam Example
The following is a brief example of a mental status exam:
- Appearance: The client is slouched and disheveled.
- General behavior:The client is uncooperative and has poor eye contact.
- Speech:The client speaks fast and soft.
- Emotions:The client states he feels "depressed and anxious."
- Thinking process: The client is incoherent and disorganized.
- Cognition: The client is focused and alert, and he performed well on working memory tests.
- Insight: The client displays poor insight.
- Judgment: The client shows fair judgment.
- Reliability: The client is unreliable because he gave false impressions of himself.
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