MSE 5/10/23

Mental Status Exam
Appearance: [select name="race" value="White|Black|Hispanic|"][conditional field="race" condition="(race).is('')"] [text ][/conditional] [select name="sex" value="male|female|transgender female|transgender male"], appearing [select name="appearance" value="approximately same as|younger than|older than"] chronological age, [checkbox name="build" value="normal build, wearing hospital gown|normal build|overweight|obese|underweight|emaciated|thin|muscular build|wearing hospital gown|wearing paper scrubs|casually dressed|oddly dressed|partially undressed"][select name="grooming" value=", adequate hygiene and grooming|, disheveled appearing|, well-groomed|, grooming notable for"] [text]
Attitude/Behavior: [checkbox name="attitude" value="lying down in bed|sitting up in bed|sitting on side of bed|sitting in bedside chair|pacing, walking around room|calm and cooperative, engages easily, socially appropriate|calm|irritable|restless|agitated|impatient|guarded|defensive|argumentative|resistant to psychiatry|poor effort and cooperation|cooperative|uncooperative|eventually cooperates|reluctantly cooperates|intermittently cooperative|easily engages|difficult to engage|socially appropriate|socially inappropriate at times|disinhibited behavior|notable grimacing with positional changes|lying in urine|lying feces|poor social awareness"] [text name="Behx" default=";"][select name="eyecontact" value="fair|good| poor|intermittent|intense|refuses|no"] eye contact
Motor Activity: [checkbox name="motor" value="normal level of activity, no abnormal movements|increased level of activity|decreased level of activity|psychomotor agitation|psychomotor retardation|no abnormal movements|tremulousness|+tremor|+tic|+dystonia"][text size=65]
Intellectual Functioning: [checkbox name="IntFxn1" value="estimated to be average|estimated to be below average|estimated to be above average|"] [select name="IntFxn2" value="|based on "][checkbox name="IntFxn3" value="interview responses|educational attainment|occupational functioning|fund of general knowledge|ability to engage in abstract thinking|"]
Judgement: [checkbox name="judgement" value="good|as evidenced by ability to anticipate outcomes|adequate|as evidenced by ability to use feedback to learn from mistakes|fair|as evidenced by ability learn from some experiences|poor|as evidenced by difficulty predicting results of choices"]


Expression and Understanding data elements assess whether a patient/resident is able to express or communicate requests, needs, and opinions; conduct social conversation; and comprehend direct person-to-person communication. Issues regarding making oneself understood (ability to communicate requests and needs) and inability to understand

Communication-Ability to express ideas and wants, consider both verbal and non-verbal expression
o 0 = Understood
o 1 = Usually understood – difficulty communicating some words or finishing thoughts but is able if prompted or given time
o 2 = Sometimes understood – ability is limited to making concrete requests
o 3 = Rarely/never understood
o 9 = Unknown or unable to assess

A5. Understanding verbal content, however able (with hearing aid or device if used)
o 0 = Understands – clear comprehension
o 1 = Usually understood – misses some part/intent of message but comprehends most conversation
o 2 = Sometimes understands – responds adequately to simple, direct communication only
o 3 = Rarely/never understands
o 9 = Unknown or unable to assess

A6. Expression of Ideas and Wants (consider both verbal and non-verbal expression and excluding language barriers)
o 4 = Expresses complex messages without difficulty and with speech that is clear and easy to understand
o 3 = Exhibits some difficulty with expressing needs and ideas (e.g., some words or finishing thoughts) or speech is not clear
o 2 = Frequently exhibits difficulty with expressing needs and ideas
o 1 = Rarely/Never expresses self or speech is very difficult to understand
o 9 = Unknown or unable to assess
A7. Understanding Verbal Content (with hearing aid or device, if used and excluding language barriers)
o 4 = Understands: Clear comprehension without cues or repetitions
o 3 = Usually Understands: Understands most conversations, but misses some part/intent of message. Requires cues at times to understand
o 2 = Sometimes Understands: Understands only basic conversation or simple, direct phrases. Frequently requires cues to understand
o 1 = Rarely/Never Understands
o 9 = Unknown or unable to assess 

--
Auditory Comprehension
Ability to understand basic verbal communication
Task: Informally engage patient in conversation; ask patient to follow single and two-stage commands.
Utilize both high and low-probability instructions.
Grade:
10=No abnormality detected on screening
8=Follows ordinary conversation with little difficulty
6=Follows simple conversation/ instructions with repetition
4=Occasional motor response if cued
2=No/minimal response to speech
--

receptive and expressive language is intact.
Language (expressive language [including naming, word finding, fluency, and grammar and syntax] and receptive language)
Major: Significant difficulties with expressive or receptive language, uses general-use phrases such as “that thing” and “you know what I mean,” with severe impairment may not recall names of close friends and family; echolalia and automatic speech typically precede mutism
Minor: Noticeable word-finding difficulty; may substitute general for specific terms, avoid use of specific names of acquaintances, grammatical errors involving subtle omission or incorrect use of articles, prepositions, auxiliary verbs, etc.
Attention
Able to direct attention and interact in interview
Able to sustain attention and engage in communication/interaction

Cooperation
Cooperative-engages in some form of exchange (verbal/nonverbal)
Fluctuating cooperation; distracted by multiple simultaneous stimuli
Reluctant; unwilling to permit interaction
Unable to cooperate with interaction or activity

Insight:  Good, as evidenced by []awareness of psychiatric condition and symptoms, []understanding of current psychiatric medications and effects of nonadherence to treatment, and [] appreciation of need for compliance with psychiatric medication and ongoing treatment. [awareness of illness and its effects, attribution of symptoms to a mental disorder, perception of need for ongoing treatment, and awareness of the achieved effects of current treatment]
Judgment: Intact,  [] able to predict consequences of choices.

Appearance: In hospital gown, well groomed, good eye contact, and ***
Behavior: Engaged readily, cooperative, appropriate.
Psychomotor:No psychomotor agitation.
Cognition:
       Level of Consciousness: Awake and alert. No fluctuation in wakefulness.
       Orientation: Person, Place, Time and Situation
       Memory: Intact
       Attention/Concentration: Fair
       Fund of Knowledge: Able to demonstrate an awareness of current events.
Mood: Euthymic
Affect: Mood-congruent and reactive within a normal range.
Speech/Language: Appropriate tone, prosody, cadence, phonetics, and syntax
Thought Form: Goal directed. No Loosening of associations
Thought Content:No delusions.
Perceptual disturbances: No hallucinations.
Safety:
       Suicidal Ideations: No suicidal ideation, intent or plan.
       Homicidal Ideations: No homicidal ideation, intent or plan.
Insight: Recognized the presence of illness.
Judgment: Appropriate.


--
Appearance: As stated age, good grooming/hygiene, wearing appropriate clothing
Behavior: Cooperative. Fair eye contact. Calm.
Gait: Steady gait
Muscle Strength/Tone: No atrophy or abnormal movements
Speech: Normal rate, tone and volume
Mood: “***”
Affect: Reactive, congruent
Thought Process: Linear, goal-directed
     - Associations: Intact
Thought Content: No suicidal or homicidal ideation. Not responding to internal stimuli. No auditory or visual hallucinations.
Attention Span and Concentration: Not distracted in conversation
Language: Able to name objects
Fund of Knowledge: Average
Memory: Both recent and remote memories are intact in context of conversation
Orientation: Intact to person, place
Insight/Judgment: ***

---

MSE NORMAL
Appearance: well groomed, appropriate dress
Interaction: cooperative
Eye Contact: appropriate
Psychomotor: appropriate
Musculoskeletal: no abnormalities in strength, tone, gait or station
Speech: normal rate and volume. Normal articulation, spontaneity and coherence
Mood: “***”
Affect: appropriate to content of interview
Thought Content: no thoughts of suicide or homicide. No paranoia or psychosis
Associations: intact
Thought Process: logical
Orientation: alert and oriented to person, place, date and day
Memory: adequate recent and remote history with no deficits
General Knowledge: adequate for age
Intellectual Function: intact with normal abstract ability. Normal concentration. Fair insight and judgment. Language normal
AIMS Negative

NORMAL MSE
Appearance: In hospital gown, well groomed, good eye contact, and ***
Behavior: Engaged readily, cooperative, appropriate.
Psychomotor:No psychomotor agitation.
Cognition:
       Level of Consciousness: Awake and alert. No fluctuation in wakefulness.
       Orientation: Person, Place, Time and Situation
       Memory: Intact
       Attention/Concentration: Fair
       Fund of Knowledge: Able to demonstrate an awareness of current events.
Mood: Euthymic
Affect: Mood-congruent and reactive within a normal range.
Speech/Language: Appropriate tone, prosody, cadence, phonetics, and syntax
Thought Form: Goal directed. No Loosening of associations
Thought Content:No delusions.
Perceptual disturbances: No hallucinations.
Safety:
       Suicidal Ideations: No suicidal ideation, intent or plan.
       Homicidal Ideations: No homicidal ideation, intent or plan.
Insight: Recognized the presence of illness.
Judgment: Appropriate.

STANDARD MSE
Appearance:Well dressed, well groomed
  Behavior: Engaged readily.
  Psychomotor: No psychomotor agitation.
  Cognition
     Level of Consciousness: 
     Orientation: Person, place, time and situation.
     Memory: Intact.
     Attention/Concentration:
     Fund of Knowledge: 
  Mood: Euthymic.
  Affect: Mood-congruent and reactive within a normal range.
  Speech/Language: Appropriate tone, prosody, cadence, phonetics, and syntax.
  Thought Form: Goal-directed. No loosening of associations.
  Thought Content: No delusions noted or endorsed.
  Perceptual Disturbances: 
  Safety:
     Suicidal Ideations: No suicidal ideation, intent or plan.
     Homicidal Ideations: No homicidal ideation, intent or plan.
  Insight: Recognized the presence of illness.
  Judgment: Appropriate

--

MSE - NORMAL
Appearance: The patient is well groomed in appropriate attire, normally developed, establishes good eye contact.
Motor: Normal gait and station, ambulates independently. No psychomotor retardation or activation.
Speech: Normal rate, volume, and rhythm. Normal articulation and prosody.
Mood: ***
Affect: Congruent with mood and within normal range.
Thought Process: Thought form is linear and logical with no loosening of associations.
Thought Content: No disordered thought or SI/HI endorsed.
Orientation: The patient is alert and oriented to person, place, time and situation.
Cognition: Short and long-term memory seem intact and without deficit. Intellect, fund of knowledge, attention and focus adequate.
Insight: Good, developmentally appropriate.
Judgment: Intact with ability to consent to treatment plan.

Delirium Language Impairment
– Word-finding difficulty/paraphasia
– Comprehension deficits
– Altered semantic content
– When severe, can mimic expressive/receptive aphasia
Mental Status Exam
Appearance: , appearing chronological age,
Attitude/Behavior: eye contact
Motor Activity:
Intellectual Functioning:
Judgement:


Expression and Understanding data elements assess whether a patient/resident is able to express or communicate requests, needs, and opinions; conduct social conversation; and comprehend direct person-to-person communication. Issues regarding making oneself understood (ability to communicate requests and needs) and inability to understand

Communication-Ability to express ideas and wants, consider both verbal and non-verbal expression
o 0 = Understood
o 1 = Usually understood – difficulty communicating some words or finishing thoughts but is able if prompted or given time
o 2 = Sometimes understood – ability is limited to making concrete requests
o 3 = Rarely/never understood
o 9 = Unknown or unable to assess

A5. Understanding verbal content, however able (with hearing aid or device if used)
o 0 = Understands – clear comprehension
o 1 = Usually understood – misses some part/intent of message but comprehends most conversation
o 2 = Sometimes understands – responds adequately to simple, direct communication only
o 3 = Rarely/never understands
o 9 = Unknown or unable to assess

A6. Expression of Ideas and Wants (consider both verbal and non-verbal expression and excluding language barriers)
o 4 = Expresses complex messages without difficulty and with speech that is clear and easy to understand
o 3 = Exhibits some difficulty with expressing needs and ideas (e.g., some words or finishing thoughts) or speech is not clear
o 2 = Frequently exhibits difficulty with expressing needs and ideas
o 1 = Rarely/Never expresses self or speech is very difficult to understand
o 9 = Unknown or unable to assess
A7. Understanding Verbal Content (with hearing aid or device, if used and excluding language barriers)
o 4 = Understands: Clear comprehension without cues or repetitions
o 3 = Usually Understands: Understands most conversations, but misses some part/intent of message. Requires cues at times to understand
o 2 = Sometimes Understands: Understands only basic conversation or simple, direct phrases. Frequently requires cues to understand
o 1 = Rarely/Never Understands
o 9 = Unknown or unable to assess

--
Auditory Comprehension
Ability to understand basic verbal communication
Task: Informally engage patient in conversation; ask patient to follow single and two-stage commands.
Utilize both high and low-probability instructions.
Grade:
10=No abnormality detected on screening
8=Follows ordinary conversation with little difficulty
6=Follows simple conversation/ instructions with repetition
4=Occasional motor response if cued
2=No/minimal response to speech
--

receptive and expressive language is intact.
Language (expressive language [including naming, word finding, fluency, and grammar and syntax] and receptive language)
Major: Significant difficulties with expressive or receptive language, uses general-use phrases such as “that thing” and “you know what I mean,” with severe impairment may not recall names of close friends and family; echolalia and automatic speech typically precede mutism
Minor: Noticeable word-finding difficulty; may substitute general for specific terms, avoid use of specific names of acquaintances, grammatical errors involving subtle omission or incorrect use of articles, prepositions, auxiliary verbs, etc.
Attention
Able to direct attention and interact in interview
Able to sustain attention and engage in communication/interaction

Cooperation
Cooperative-engages in some form of exchange (verbal/nonverbal)
Fluctuating cooperation; distracted by multiple simultaneous stimuli
Reluctant; unwilling to permit interaction
Unable to cooperate with interaction or activity

Insight: Good, as evidenced by []awareness of psychiatric condition and symptoms, []understanding of current psychiatric medications and effects of nonadherence to treatment, and [] appreciation of need for compliance with psychiatric medication and ongoing treatment. [awareness of illness and its effects, attribution of symptoms to a mental disorder, perception of need for ongoing treatment, and awareness of the achieved effects of current treatment]
Judgment: Intact, [] able to predict consequences of choices.

Appearance: In hospital gown, well groomed, good eye contact, and ***
Behavior: Engaged readily, cooperative, appropriate.
Psychomotor:No psychomotor agitation.
Cognition:
Level of Consciousness: Awake and alert. No fluctuation in wakefulness.
Orientation: Person, Place, Time and Situation
Memory: Intact
Attention/Concentration: Fair
Fund of Knowledge: Able to demonstrate an awareness of current events.
Mood: Euthymic
Affect: Mood-congruent and reactive within a normal range.
Speech/Language: Appropriate tone, prosody, cadence, phonetics, and syntax
Thought Form: Goal directed. No Loosening of associations
Thought Content:No delusions.
Perceptual disturbances: No hallucinations.
Safety:
Suicidal Ideations: No suicidal ideation, intent or plan.
Homicidal Ideations: No homicidal ideation, intent or plan.
Insight: Recognized the presence of illness.
Judgment: Appropriate.


--
Appearance: As stated age, good grooming/hygiene, wearing appropriate clothing
Behavior: Cooperative. Fair eye contact. Calm.
Gait: Steady gait
Muscle Strength/Tone: No atrophy or abnormal movements
Speech: Normal rate, tone and volume
Mood: “***”
Affect: Reactive, congruent
Thought Process: Linear, goal-directed
- Associations: Intact
Thought Content: No suicidal or homicidal ideation. Not responding to internal stimuli. No auditory or visual hallucinations.
Attention Span and Concentration: Not distracted in conversation
Language: Able to name objects
Fund of Knowledge: Average
Memory: Both recent and remote memories are intact in context of conversation
Orientation: Intact to person, place
Insight/Judgment: ***

---

MSE NORMAL
Appearance: well groomed, appropriate dress
Interaction: cooperative
Eye Contact: appropriate
Psychomotor: appropriate
Musculoskeletal: no abnormalities in strength, tone, gait or station
Speech: normal rate and volume. Normal articulation, spontaneity and coherence
Mood: “***”
Affect: appropriate to content of interview
Thought Content: no thoughts of suicide or homicide. No paranoia or psychosis
Associations: intact
Thought Process: logical
Orientation: alert and oriented to person, place, date and day
Memory: adequate recent and remote history with no deficits
General Knowledge: adequate for age
Intellectual Function: intact with normal abstract ability. Normal concentration. Fair insight and judgment. Language normal
AIMS Negative

NORMAL MSE
Appearance: In hospital gown, well groomed, good eye contact, and ***
Behavior: Engaged readily, cooperative, appropriate.
Psychomotor:No psychomotor agitation.
Cognition:
Level of Consciousness: Awake and alert. No fluctuation in wakefulness.
Orientation: Person, Place, Time and Situation
Memory: Intact
Attention/Concentration: Fair
Fund of Knowledge: Able to demonstrate an awareness of current events.
Mood: Euthymic
Affect: Mood-congruent and reactive within a normal range.
Speech/Language: Appropriate tone, prosody, cadence, phonetics, and syntax
Thought Form: Goal directed. No Loosening of associations
Thought Content:No delusions.
Perceptual disturbances: No hallucinations.
Safety:
Suicidal Ideations: No suicidal ideation, intent or plan.
Homicidal Ideations: No homicidal ideation, intent or plan.
Insight: Recognized the presence of illness.
Judgment: Appropriate.

STANDARD MSE
Appearance:Well dressed, well groomed
Behavior: Engaged readily.
Psychomotor: No psychomotor agitation.
Cognition
Level of Consciousness:
Orientation: Person, place, time and situation.
Memory: Intact.
Attention/Concentration:
Fund of Knowledge:
Mood: Euthymic.
Affect: Mood-congruent and reactive within a normal range.
Speech/Language: Appropriate tone, prosody, cadence, phonetics, and syntax.
Thought Form: Goal-directed. No loosening of associations.
Thought Content: No delusions noted or endorsed.
Perceptual Disturbances:
Safety:
Suicidal Ideations: No suicidal ideation, intent or plan.
Homicidal Ideations: No homicidal ideation, intent or plan.
Insight: Recognized the presence of illness.
Judgment: Appropriate

--

MSE - NORMAL
Appearance: The patient is well groomed in appropriate attire, normally developed, establishes good eye contact.
Motor: Normal gait and station, ambulates independently. No psychomotor retardation or activation.
Speech: Normal rate, volume, and rhythm. Normal articulation and prosody.
Mood: ***
Affect: Congruent with mood and within normal range.
Thought Process: Thought form is linear and logical with no loosening of associations.
Thought Content: No disordered thought or SI/HI endorsed.
Orientation: The patient is alert and oriented to person, place, time and situation.
Cognition: Short and long-term memory seem intact and without deficit. Intellect, fund of knowledge, attention and focus adequate.
Insight: Good, developmentally appropriate.
Judgment: Intact with ability to consent to treatment plan.

Delirium Language Impairment
– Word-finding difficulty/paraphasia
– Comprehension deficits
– Altered semantic content
– When severe, can mimic expressive/receptive aphasia

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