Clinical template
Mental State Examination Template with Examples
A mental state examination (MSE) is the psychiatric equivalent of a physical exam: what you observe in this encounter, not the life history. Use the blank below, then three fictional Canadian cases written the way a family physician, emergency psychiatrist, or geriatric psychiatrist would chart them.
Blank MSE template
Copy this into your EMR or a Scribeberry custom template. Record observations from this visit. Put history, collateral, and the formulation in the HPI or assessment, not in the MSE.
Mental state examination
Date / time: Clinician / setting: clinic / ED / ward / virtual Patient: [initials, age, sex] | Informant: patient / collateral (who) Language of interview / interpreter: Appearance: age-appearance, hygiene, dress, nutritional state, distinguishing features, evidence of injury or substance use Behaviour: eye contact, psychomotor activity, cooperation, agitation or retardation, abnormal movements Speech: rate, rhythm, volume, quantity, latency, coherence, accent / dysarthria Mood (patient's words): Affect (observed): range, reactivity, congruence, lability Thought form: linear / circumstantial / tangential / flight of ideas / loosening / blocking / poverty Thought content: worries, obsessions, delusions (theme, conviction, insight), ideas of reference, SI/HI (plan, intent, means, protective factors) Perception: hallucinations (modality, command, insight), illusions, depersonalization / derealization Cognition: orientation (person, place, time), attention, memory, language, visuospatial, abstraction. Screen used (MoCA / MMSE / clock) and score if done Insight: none / partial / good — what the patient understands about illness and need for treatment Judgment: capacity to make the decision at hand (treatment, discharge, driving, childcare) Risk summary (this visit): suicide / homicide / self-neglect / vulnerability / absconding Capacity comment (if relevant):
Fictional patients
Every example on this page uses made-up names and findings. They are teaching material. They are not a substitute for college standards, Form 1 criteria, or your own clinical judgment. Review every generated note before it enters the chart.
What each heading is for
The MSE is a snapshot. A 22-year-old who is mute in the ED at 02:00 may be conversational at 10:00 after sleep and a meal. Date and time the exam. If collateral changes the picture, say so in the note, not inside the MSE headings.
| Heading | What belongs here | What does not |
|---|---|---|
| Appearance / behaviour | What you see: grooming, eye contact, tremor, pacing, cooperation | Childhood history or a diagnosis |
| Speech | How they talk: rate, volume, latency, dysarthria, pressure | The story they told (that is HPI / thought content) |
| Mood / affect | Mood in their words; affect as you observed it, including congruence | 'Appears depressed' with no description of face, range, or tears |
| Thought form / content | How ideas connect, and what they are about, including SI/HI and delusions | Your formulation or DSM label |
| Perception | Hallucinations, illusions, dissociation, with modality and insight | 'No AH/VH' copied forward when you did not ask |
| Cognition | Orientation, attention, memory, and any screen you actually administered | A guessed MoCA you did not perform |
| Insight / judgment | Whether they recognize illness and can weigh the decision in front of them | A global 'poor insight' with no example |
Canadian charts often live beside a Form 1, Form 42, or provincial equivalent. The MSE has to support why the person met, or did not meet, criteria for involuntary assessment. CMPA and provincial colleges treat that as a high-stakes note: quote enough of the patient's words that a reviewer can see the risk, and record the time.
How to write each heading
Appearance and behaviour come first because they are available before the patient speaks. Note if they came in a hospital gown, winter coat in July, or with ligature marks. Psychomotor retardation in a depression intake is a finding, not flavour text. Akathisia after a new antipsychotic belongs here, with the drug named in the medication list.
Speech is the vehicle. Poverty of speech and latency of 8–10 seconds in a melancholic depression is different from pressured, uninterruptible speech in mania. If English is a second language, say so, and whether an interpreter was used. Dysarthria after a fall is a neurologic finding that still belongs on the MSE if you noticed it during the interview.
Mood is quoted. Affect is described: restricted, tearful when discussing the baby, congruent, or a flat face with a reported mood of 'fine.' Incongruence is worth a sentence. Labile affect after a stroke or in a disinhibited frontal presentation is not the same as tearfulness in grief.
Thought form is how ideas link. Linear is the default; write it when it is true so the next reader knows you looked. Circstantial speech that returns to the point is not loosening. Loosening, clang, and word salad need examples in quotes. Thought content holds delusions, obsessions, rumination, and the suicide and homicide questions you asked, including plan, intent, means, and what stops them.
Perception needs the modality. 'Voices telling me not to eat' is usable. 'Psychotic' is not. Ask about command hallucinations and whether the patient feels able to resist. Cognition is tested, not inferred from vocabulary. If you did a clock draw or MoCA, record the score and which items failed. Insight is specific to this illness today. Judgment is specific to this decision: leaving AMA, driving, caring for a toddler overnight.
Example 1 — depression intake
Outpatient psychiatry, family-medicine referral
41-year-old woman, Vancouver. 50-minute new consult. Fictional.
Appearance: Appears stated age. Casual clothes, hair unwashed, no makeup (patient states this is a change). No odour of alcohol. No visible injuries. BMI lean; 6 kg loss reported.
Behaviour: Sits on edge of chair, limited eye contact, psychomotor slowing (delayed shift in posture). Cooperative, no agitation, no abnormal movements.
Speech: Quiet, normal rate once started, latency 5–8 s, reduced quantity, no dysarthria, no pressure.
Mood: "heavy, like I'm already tired when I wake up."
Affect: Restricted, tearful when discussing her 8-year-old, congruent, not labile. Brightened briefly when discussing a colleague.
Thought form: Linear, no loosening, no flight of ideas, mild poverty of content.
Thought content: Ruminative self-criticism ("I'm failing at work and at home"). No delusions. No obsessions. SI: passive "I wish I wouldn't wake up" most mornings x 3 weeks; no plan, no intent, no rehearsal, no access to firearms. Protective: daughter, mother in Burnaby. No HI.
Perception: No AH/VH, no illusions, no depersonalization.
Cognition: Oriented x3. Attention intact on serial 7s. Delayed recall 3/3 at 5 min. No screen formally scored today.
Insight: Good — identifies a depressive episode, agrees she is worse than in 2019, willing to consider medication.
Judgment: Intact for treatment decisions today; has already arranged childcare for follow-up.
Risk this visit: low-moderate suicide risk (passive SI, no plan/intent, strong protective factors, engaged). No self-neglect requiring urgent housing intervention.Example 2 — first-episode psychosis, ED
Emergency psychiatry
22-year-old man, Hamilton General ED. 02:40. Brought by EMS after parents called 911. Fictional.
Appearance: Thin, stated age. Hospital gown over street clothes. Hair matted. Dry lips. Small abrasion over left knuckle (parents: punched a wall). No track marks. Behaviour: Avoids eye contact, repeatedly looks at the ceiling corner, intermittently whispers. Guarded. Mild psychomotor agitation (rocks, stands twice, sits when asked). No catatonic posturing. Cooperative enough to stay for interview with father in room. Speech: Normal volume then drops to whisper; rate normal; latency variable; content interrupted by pausing to "listen." No dysarthria. Not pressured. Mood: "scared they already got into the vents." Affect: Fearful, restricted, congruent with persecutory theme, not labile. Thought form: Circumstantial, occasional tangentiality, no frank word salad. No clang. Some blocking when asked about the vents. Thought content: Persecutory delusion that former classmates installed cameras in the apartment 2 weeks ago; idea of reference from a bus advertisement. No grandiose or religious delusions elicited. SI: denies wanting to die; "I just want them to stop." HI: denies intent to harm identified people; knuckle injury from wall, not a person. No organized plan to confront classmates. Perception: +AH, male voices, two, commenting on his actions, occasional command "don't take their pills." Patient uncertain if real. No VH. No tactile. Cognition: Oriented to hospital and month, not to day. Attention impaired (could not complete WORLD backwards). Registration 3/3, delayed 1/3. Not formally MoCA'd at 02:40. Insight: Poor — attributes events to surveillance, not illness. Will consider staying "if my dad says so." Judgment: Impaired for discharge safety; cannot plan food, rent, or follow-up. Father reports 4 days without eating properly. Risk this visit: high for deterioration and self-neglect; moderate for impulsive aggression if cornered; no current HI plan. Does not meet a safe-discharge threshold. Form 1 completed (Ontario). Security in view. Offer of olanzapine 5 mg discussed with patient and father.
Example 3 — geriatric cognitive assessment
Geriatric psychiatry, memory clinic
78-year-old man, Winnipeg. Daughter present. 45-minute visit. Fictional.
Appearance: Appears older than stated age. Clean shirt, mismatched shoes (daughter dressed him). Hearing aids in. No bruises. Well nourished.
Behaviour: Pleasant, socially appropriate greeting, then looks to daughter for answers. Mild restlessness in the second half. No agitation, no Parkinsonian tremor, no myoclonus.
Speech: Slightly reduced rate, normal volume, word-finding pauses, occasional semantic paraphasia ("the cooking box" for oven). No dysarthria, no pressure.
Mood: "I'm fine. She's the one who's worried."
Affect: Euthymic, restricted range, reactive to humour, congruent. No lability, no tearfulness.
Thought form: Circumstantial. Returns to hunting stories. No loosening.
Thought content: Minimizes memory loss. No delusions of theft today (daughter: accused neighbour of stealing mail last month). No SI/HI. Preoccupied with "getting my licence back" (licence surrendered 6 months ago after a near-miss).
Perception: Denies AH/VH. Daughter: no responding-to-unseen-people at home. No Charles Bonnet described.
Cognition: Oriented to person and city, not to year (said 2019) or clinic name. MoCA 16/30 (visuospatial 1/5, attention 3/6, delayed recall 0/5, orientation 4/6). Clock: numbers crowded to right, hands absent. Cannot name prime minister; names his late wife correctly.
Insight: Poor regarding driving and finances; partial regarding "I forget names."
Judgment: Impaired for driving and banking. Agrees to daughter managing bills when framed as "temporary help."
Risk this visit: driving risk already addressed (licence surrendered). Home safety: lives with daughter, stove still used unsupervised at lunch — recommend stove-timer / supervision. No acute suicide risk. No capacity to make a complex financial decision today; personal-care decisions should be revisited with more time and a quieter room.Mistakes that show up in charts
- Copy-forwarding last week's MSE, including a MoCA you did not repeat.
- Writing 'NAD, speech normal, no SI' as the entire exam in a first-episode presentation.
- Putting the DSM diagnosis inside thought content.
- Recording 'no AH' when you never asked, especially in a guarded patient.
- Skipping suicide and homicide questions because the patient 'looked fine.'
- Stating 'poor insight' with no example the college or CMPA could read.
- Omitting time, setting, and whether an interpreter was used.
- Using the MSE to dump the entire developmental history.
CMPA's documentation advice is consistent across provinces: if a risk question or a capacity discussion is not in the record, it is hard to show it happened. Colleges expect you to correct an AI draft before you sign. The person who signs the MSE owns the Form 1, the discharge, and the driving advice.
MSE vs history, and where Scribeberry fits
History of present illness is the story over days or months. The MSE is this hour. Collateral from a parent or a CCAC worker is labelled as collateral. Mixing them produces a note that looks complete and still cannot answer 'what were they like at 02:40.' Keep the headings even on a virtual visit; write that you could not assess gait or smell of alcohol.
Draft the MSE from the encounter
Scribeberry listens to the visit, or takes dictation, and fills your MSE headings. Edit the quotes, the risk line, and any Form decision, then Smart Push into Accuro, OSCAR, Jane, or any web EMR. Pro is $99/month after the free trial.
Frequently asked questions
What is a mental state examination?
An MSE is a structured record of appearance, behaviour, speech, mood and affect, thought form and content, perception, cognition, insight, and judgment as observed in this encounter. It is the psychiatric physical exam, not the biography.
How is an MSE different from a psychiatric history?
The history covers onset, course, past episodes, substances, trauma, and social context. The MSE covers what you see and hear today. A patient can give a calm history of last month's panic attacks and still have a normal MSE, or a chaotic MSE with a thin history because they cannot tell it.
Do I need a MoCA or MMSE in every MSE?
No. Use a screen when cognition is in question (memory clinic, delirium, new psychosis, post-overdose). Record the name of the tool, the score, and which domains failed. Do not invent a score. Orientation plus attention plus three-word recall is acceptable when a full screen is not indicated.
Can Scribeberry generate an MSE?
Yes. Pick an MSE template (or your own headings), record or dictate the interview, and generate. You review quotes, risk, and legal forms before the note goes to the EMR. Custom templates keep the heading order your service uses.
Templates
