Mental Status Exam Notes

 The Mental Status Exam (MSE)

Purpose

The Mental Status Exam (MSE) is a series of questions and 

observations that provide a snapshot of a client's current mental, 

cognitive, and behavioral condition.

Goals

The Mental Status Exam has the following three goals:

(1)

To get a baseline measure of psychological functioning

(2)

To get a measure of biological, psychological and social 

factors that predisposed, precipitated, and perpetuate the 

client's current functioning

(3)

To establish a client's capacity to function.

When to Use

The Mental Status Exam is done during first interviews, when there 

is reason to believe a client is cognitively altered, and during a 

crisis or emergency situation.

**Safety for the client and/or the worker takes priority over

completing the Mental Status Examination**

Procedure The Mental Status Examination is best done through the normal 

progress of a first interview, by observing a client's verbal and non￾verbal behavior. Areas of inquiry include:

(1)

Observations of appearance, activity level, behavior, 

speech, and attitude toward the interviewer

(2)

Level of consciousness

(3)

Thought content

(4)

Affect and Mood

(5)

Cognition, reality contact, memory

(6)

Confidence in information given.

See The Form MSE for step by step instructions and a list of questions.