MSE – quick template

Mental Status Examination & Other

[checkbox name="details" value="presented on time for scheduled counseling session|engaged and cooperative|avoidant or disengaged"]

Setting:
[checkbox name="setting" value="in-person|telehealth|verbally consented to telemental health counseling|no video available for session"]

General:
[checkbox name="Orient" value="alert x4|disoriented"]

Appearance:
[checkbox name="Appearance" value="WNL|poor hygiene|poor grooming|inappropriately dressed"]

Mood:
[checkbox name="Mood" value="euthymic|anxious|depressed|hypomanic|angry|agitated|frustrated|grief/loss|restless"]

Speech:
[checkbox name="Speech" value="WNL|soft|hurried|loud|forced"]

Behavior:
[checkbox name="Behavior" value="WNL|agitated|tired/fatigued|depressed|anxious"]

Eye Contact:
[checkbox name="Eye" value="WNL|fair|avoidant"]

Affect:
[checkbox name="Affect" value="WNL-congruent|flat|labile|blunted|broad|restricted"]

Thought Content:
[checkbox name="Thought" value="WNL|goal-directed|past-oriented|tangential|rapid-fire|delusions|concrete|obsessive|preoccupied"]

Cognition/Memory:
[checkbox name="CM" value="intact|impaired"]

Perception:
[checkbox name="Perception" value="good insight|fair insight|poor insight"]

Risk for Suicide or Self-harm:
[checkbox name="harm" value="none identified|in distress|Hx self-harm|Hx SI|Hx previous suicide attempt(s)|denies SI/HI|denies intent|denies plan|denies means|endorses passive SI/HI|endorses active SI/HI|endorses plan|endorses intent|endorses means|self-harm:passive|self-harm:active"]

Protective Factors:
[checkbox name="protective" value="Social support|Family|Future-oriented|Rx compliance|Tx compliance|Other protective factor(s)|N/A"]

Risk Assessment:
[select name="risk" value="low|moderate|HIGH"]

Progress:
[select name="progress" value="Actively making progress|Making some progress|Planning|No observable progress|Not engaged in session|Not engaged in therapy"]

Interventions:
1. [select name="intervention_1" value="Processed thoughts and feelings since last visit|Validated and normalized|CBT-Cognitive Restructuring|Person-centered|ACT|Creative visualization|Breathing exercise|Grounding exercise|Case management|Psychoeducation|Other(see below)"]
2. [select name="intervention_2" value="Processed thoughts and feelings since last visit|Validated and normalized|CBT-Cognitive Restructuring|Person-centered|ACT|Creative visualization|Breathing exercise|Grounding exercise|Case management|Psychoeducation|Other(see below)"]
3. [select name="intervention_3" value="Processed thoughts and feelings since last visit|Validated and normalized|CBT-Cognitive Restructuring|Person-centered|ACT|Creative visualization|Breathing exercise|Grounding exercise|Case management|Psychoeducation|Other(see below)|N/A"]


Topics Discussed:
[textarea name="variable_1" default="1. "]

Plan:
[select name="variable_1" value="Continue Counseling|Continue Consult|d/c - non-compliance|d/c - referral|d/c - no further services recommended at this time"]