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:

 

Examples of observation detail:

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.

Attitude and Behavior

  • Is the person cooperative, irritable, belligerent etc.?
  • Is there any indication of malingering or factitious behavior?  Explain.

Mood and Affect

  • How does the person describe his or her mood?
  • Is the person’s affect congruent with the stated mood? Explain.

Content of Thought

  • Are there any delusions?
  • Is the person suicidal?  Homicidal?  What leads you do this conclusion?

Stream of Mental Activity

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

Orientation

  • Is the person oriented times three?

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?

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?

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.

Abstract Thinking

  • Interpret proverbs?  Give examples.

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?