Mental Status Exam Guidelines
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Mental Status Exam Guidelines


Revised December 12, 2011



A mental status exam (MSE) must accompany all mental health reports for determination of Disability based benefits. A MSE must be included with the submission of DSHS form 13-865.

A mini mental status exam (MMSE) cannot be substituted for a MSE.

MSE GUIDELINES

Every MSE must include observation detail for each of the categories listed below. Individual questions may be altered and additional questions may be added:

Category

Examples of observation detail:

a.    General Appearance

·         Well groomed or unkempt?

·         What is the person wearing? 

·         Are clothes appropriate for weather and situation?

·         Evidence of psychomotor agitation or retardation?  Give examples.

b.    Attitude and Behavior

·         Is the person cooperative, irritable, belligerent etc.?

·         Is there any indication of malingering or factitious behavior?  Explain.

c.    Mood and Affect

·         How does the person describe his or her mood?

·         Is the person’s affect congruent with the stated mood?  Explain.

d.    Content of Thought

·         Are there any delusions?

·         Is the person suicidal?  Homicidal?  What leads you do this conclusion?

e.    Stream of Mental Activity

·         Is speech normal or tangential or circumstantial?  Give Examples.

f.     Orientation

·         Is the person oriented times three?

g.    Memory

·         Remote—can person remember past events?

·         Recent—can person remember 3/3 objects after 5 min?

·         Immediate—how well can the person do digit span back and forward?

h.    Fund of Knowledge

·         Is the person aware of current events?  Give examples.

·         Does the person know the names of the president and governor?

·         Can the person answer simple geography questions, such as naming bordering states?

i.      Concentration

·         Serial 7’s or 3’s?  Give person’s response.

·         Spell WORLD forward and backward?

·         Follow a three step command?

·         Difficulty following conversation.  Give examples.

j.      Abstract Thinking

·         Interpret proverbs?  Give examples.

k.    Insight and Judgment

·         Does the person have insight into his/her condition?

·         Does the person show good judgment when asked what he/she would do if smelling smoke in crowded theater?

Modification Date: December 12, 2011