Mental status exams are a vital component of mental health assessments, helping clinicians evaluate a patient’s cognitive function, behavior, and emotions. These exams provide valuable insights into a patient’s mental state and can help guide treatment decisions. In this article, we will discuss the 10 best templates, questions, and examples for conducting a mental status exam.

1. General appearance and behavior: Begin by observing the patient’s overall appearance and behavior. Note their grooming, clothing, posture, and eye contact. Ask about any changes in their behavior or habits.

Example question: “Can you tell me about your daily routine and how it has changed recently?”

2. Mood and affect: Assess the patient’s mood (their emotional state) and affect (their emotional expression). Pay attention to their facial expressions, tone of voice, and body language.

Example question: “How have you been feeling lately? Can you describe your mood for me?”

3. Thought process: Evaluate the patient’s thought process by assessing their coherence, logic, and organization of thoughts. Look for signs of tangential thinking, racing thoughts, or disorganized speech.

Example question: “Can you tell me about what you were thinking when you made that decision?”

4. Thought content: Inquire about the content of the patient’s thoughts, including any delusions, obsessions, or preoccupations. Ask about any paranoia or suicidal thoughts.

Example question: “Have you been experiencing any unusual or distressing thoughts lately?”

5. Perception: Evaluate the patient’s sensory perceptions, including hallucinations or illusions. Ask about any changes in their perception of reality.

Example question: “Have you been hearing or seeing things that others don’t?”

6. Memory: Assess the patient’s memory by asking about recent events or information. Test their immediate, short-term, and long-term memory.

Example question: “Can you tell me what you had for breakfast this morning?”

7. Orientation: Determine the patient’s orientation to time, place, and person. Ask about the current date, location, and their own identity.

Example question: “Do you know where you are right now and what day it is?”

8. Cognitive function: Evaluate the patient’s cognitive function by testing their attention, concentration, and problem-solving abilities. Ask them to perform simple cognitive tasks.

Example question: “Can you count backward from 100 by sevens for me?”

9. Insight and judgment: Assess the patient’s insight into their condition and their ability to make sound decisions. Inquire about their awareness of their mental health issues.

Example question: “Do you understand why you’re here today and what we’re discussing?”

10. Overall impression: Finally, provide an overall impression of the patient’s mental status, including any relevant observations or concerns. Summarize your findings and make recommendations for further evaluation or treatment.

Conducting a thorough mental status exam is essential for accurately assessing a patient’s mental health. By using these templates, questions, and examples, clinicians can gather valuable information about a patient’s cognitive function, behavior, and emotions. This information can help guide treatment decisions and improve patient outcomes.