Frequently Asked Questions:
Mental Status Examination
What are the most common mistakes made during a Mental Status Examination?
The Mental Status Examination (MSE) is a core component of behavioral health assessment, offering a snapshot of a client’s cognitive, emotional, and psychological functioning. But even experienced clinicians can overlook important details or fall into documentation traps that weaken the clinical utility—and legal defensibility—of the note. Fortunately, using a structured EHR like ICANotes can help minimize these risks by guiding clinicians through each domain with professionally worded templates and decision-support tools.
Here are the most common MSE mistakes—and how to avoid them:
1. Relying Too Heavily on First Impressions
It’s natural to form impressions quickly, but anchoring bias can cause you to miss signs that contradict your initial assumptions.
Tip: Stay curious and systematically assess each domain of the MSE rather than jumping to conclusions based on appearance or attitude.
ICANotes Advantage: The MSE template in ICANotes walks clinicians through each domain in sequence, reducing the risk of skipping areas or anchoring on initial observations.
2. Failing to Use the Client’s Own Words for Mood
Mood should be self-reported, not inferred. Avoid assuming a mood state based solely on appearance or tone.
Tip: Always ask directly: “How would you describe your mood?” and document the response verbatim.
ICANotes Advantage: ICANotes offers smart text options that prompt the clinician to enter direct client quotes and flag whether mood is self-reported or clinician-observed.
3. Confusing Mood with Affect
These two domains are often mixed up.
- Mood is what the client says they feel.
- Affect is what you observe.
Common mistake: Writing “client appears anxious” under mood instead of under affect.
Fix: Document anxious presentation under affect, and use the client’s own wording for mood.
ICANotes Advantage: Separate fields for mood and affect in ICANotes, with point-and-click choices and editable narrative options, help prevent this confusion.
4. Overlooking Subtle Signs of Risk
Clinicians sometimes miss passive suicidal ideation, psychotic features, or poor insight if they don’t ask directly or probe further.
Tip: Always assess safety, insight, and judgment—even if the client seems high-functioning.
ICANotes Advantage: Built-in prompts and templates for suicide/homicide risk, hallucinations, and delusions help ensure critical risk factors are addressed and clearly documented.
5. Using Vague or Jargon-Laden Language
Terms like “appropriate,” “intact,” or “normal” lack precision and may be questioned in legal or insurance reviews.
Tip: Be specific and descriptive. Instead of “thought process normal,” write “thought process linear and goal-directed.” Instead of “speech appropriate,” use “speech clear, spontaneous, and of normal rate and volume.”
ICANotes Advantage: ICANotes’ phrase builder encourages detailed, clinically meaningful descriptions instead of vague generalizations.
6. Skipping Domains or Inconsistent Documentation
In fast-paced settings, clinicians may skip less “obvious” domains like insight, abstract thinking, or impulse control.
Tip: Use a standardized template or checklist to ensure consistency or a pre-built MSE structure like ICANotes offers.
ICANotes Advantage: ICANotes’ MSE note structure includes all standard domains (appearance, behavior, mood, affect, speech, thought process/content, cognition, perception, insight, and judgment), ensuring consistent and comprehensive documentation.
7. Not Considering Cultural and Developmental Contexts
Behavior may appear “inappropriate” when it's actually culturally or developmentally normative.
Tip: Consider language, cultural background, neurodiversity, and developmental stage before labeling behavior as impaired.
ICANotes Advantage: ICANotes allows for custom narrative input, so clinicians can add context and clarify behaviors that may be culturally specific or age-appropriate.
Bottom Line:
A high-quality MSE is:
- Systematic (covering all domains),
- Descriptive (not vague),
- Neutral (nonjudgmental), and
- Clinically actionable (guiding diagnosis and treatment).
Using a documentation system like ICANotes helps clinicians avoid the most common MSE pitfalls by providing structured templates, intuitive dropdowns, and editable narratives that reduce errors and boost clarity—all while saving time.
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