Mental State Examination (MSE) Notes Using DocScrib Templates

Updated on: September 29, 2025

Introduction

In mental health assessment and psychiatric practice, the Mental State Examination (MSE) is a cornerstone tool. The MSE captures a snapshot of a person’s psychological functioning at a particular moment in time, covering domains such as appearance, speech, mood, thought content, cognition, insight, judgment, and more. It is essential for diagnosis, monitoring changes over time, informing treatment planning, and communicating effectively across care teams.

Yet clinicians often find writing MSEs laborious—balancing comprehensiveness with clarity, under time pressure, avoiding omissions, and integrating observational insight with structured data. A well-designed template can alleviate some of that burden. Even better is a template enhanced with AI support, such as one integrated into DocScrib, which can help prefill, suggest, check consistency, and free you to focus on clinical nuance.

In this blog, we will:

1. Explain what the MSE is, its purpose and key domains
2. Review challenges clinicians face in writing MSEs
3. Present a detailed, flexible DocScrib MSE Template
4. Discuss how DocScrib’s AI tooling can support and augment MSE documentation
5. Provide charts to illustrate efficiency gains and feature comparisons
6. Show multiple example MSE write-ups (psychiatric, neurological)
7. Share best practices, pitfalls to avoid, and tips
8. Conclude with a call to action

What Is the Mental State Examination (MSE)?

Definition & Purpose

The Mental State Examination is a structured clinical assessment of a person’s current mental functioning. It combines interview data (what the patient says), clinical observation (how the patient behaves), and brief cognitive testing (orientation, memory, concentration).

The MSE provides a baseline snapshot of functioning that helps:

• Support diagnostic hypotheses
• Monitor change over time (improvement, deterioration)
• Communicate findings to other clinicians
• Alert to risk (suicidality, psychosis, cognitive decline)
• Guide treatment planning

Because mental state can vary, repeated MSEs (e.g., at admission, at key intervals, or when mental status changes) are clinically useful.

Common Domains / Components

While headings vary, most MSE templates include the following:

1. Appearance & Behavior
2. Attitude / Rapport
3. Motor Activity / Psychomotor
4. Speech
5. Mood & Affect
6. Thought Process (Form / Flow)
7. Thought Content
8. Perception
9. Cognition / Orientation / Memory / Attention
10. Insight
11. Judgment
12. Risk / Safety

Some templates add Fund of Knowledge, Abstract Thinking, Concentration tests, or Impulse Control. Cognitive screening tools like MMSE or MoCA can be embedded within the cognition domain when indicated.

Challenges in Writing MSEs

• Time constraints: Busy schedules leave limited time to document thoroughly.
• Cognitive burden: Tracking every domain while engaging the client is demanding.
• Omissions / inconsistencies: Easy to forget insight or risk when rushed.
• Narrative vs structure: Too rigid feels stifling; too narrative risks missing key headings.
• Clarity and objectivity: Describing affect, thought form, or content precisely is an art.
• Integration: Pulling past MSEs, results, or history manually is tedious.
• Risk documentation: Safety-related content must be explicit and defensible.
• Legal / audit scrutiny: MSEs must be clear, complete, and timestamped.

A high-quality template helps—pairing that with AI assistance helps even more.

DocScrib MSE Template — Design & Structure

Below is a detailed, adaptable DocScrib MSE Template designed for clinical flexibility, clarity, and AI integration. Collapse, branch, or skip sections when not applicable.

DocScrib MSE Template

Header / Identification

• Patient Name / ID
• Date / Time of Assessment
• Assessor / Clinician & Role
• Setting / Location (Inpatient, Outpatient, Emergency, Telepsychiatry)
• Context / Reason for MSE (Admission, Routine, Change in mental status)

Appearance & Behavior

• Grooming, hygiene, clothing, posture, facial expression
• Eye contact, demeanor (calm, guarded, hostile, irritable)
• Motor activity (agitation, retardation, tremor, tics)

Attitude / Rapport

• Cooperative, guarded, evasive, defensive, hostile, passive
• Quality of engagement with interviewer

Speech

• Rate (slowed, normal, pressured), volume (soft, normal, loud)
• Latency, fluency, articulation, prosody
• Coherence and connectedness to thought process

Mood & Affect

• Mood (subjective): patient’s self-report (“I feel…”)
• Affect (objective): range, reactivity, congruence with stated mood
• Intensity and stability (labile, blunted, flat)

Thought Process / Form

• Flow: linear, goal-directed, circumstantial, tangential, loosening, flight of ideas, blocking
• Organization, coherence

Thought Content

• Delusions, obsessions, overvalued ideas
• Suicidal / homicidal ideation (thoughts, plan, intent)
• Preoccupations (guilt, worthlessness) or notable denials

Perception

• Hallucinations (auditory, visual, tactile, gustatory, olfactory)
• Illusions, depersonalization/derealization
• Insight into perceptual experiences

Cognition / Orientation / Memory / Attention

• Orientation: person, place, time, situation
• Attention / Concentration: serial 7s, spelling backwards
• Memory: immediate, recent (short-delay recall), remote
• Fund of knowledge / general information
• Abstract thinking: proverb interpretation, similarities
• Executive function as clinically indicated

Insight

• Awareness of illness and need for treatment
• Attributions for symptoms; capacity to self-monitor

Judgment

• Decision-making capacity, understanding of consequences
• Recent examples of judgment-related behavior

Risk / Safety

• Suicidal or self-harm ideation, plan, intent, means
• Homicidal ideation or aggression risk
• Self-neglect or vulnerability
• Protective factors and safety plan

Summary / Impressions

• Concise synthesis of key abnormalities and implications
• Severity, differentials if relevant, immediate priorities

Signature / Timestamp / Versioning

• Clinician name / designation
• Date and time of documentation
• Version or edit history (if applicable)

Adaptive Features & Design Notes

• Mandatory vs optional subfields, with collapsible sections
• Branch logic for perceptual or risk content
• Prefill & recall from prior MSEs, with update prompts
• Editable narrative blocks alongside structured fields
• Semantic tagging for analytics (e.g., “thought disorder”)
• Audit trail & versioning for transparency
• Hide-if-normal rendering to keep notes concise when WNL

How DocScrib AI Enhances MSE Documentation

1) Voice / Transcript Integration
With consent, voice capture or transcription can be parsed into the appropriate headings. Mentions of “voices,” “hopeless,” or “racing thoughts” are routed to perception, mood, or thought content.

2) Smart Suggestions / Autocomplete
While typing, DocScrib can propose clinically standardized phrasing and options (e.g., “affect constricted, congruent to mood”), improving consistency and speed.

3) Prefill Historical Data
Key prior findings (e.g., baseline cognition, prior hallucination types) can be preloaded, requiring only updates.

4) Omission & Consistency Checks
If suicidality is mentioned in thought content, DocScrib prompts to complete the risk section. If hallucinations are cited, perception prompts expand automatically.

5) Standardization & Coding
Terminology can be normalized, and findings mapped to internal codes or billing frameworks (kept behind the scenes), aiding analytics and reimbursement workflows.

6) Trend Tracking & Summaries
Over serial MSEs, DocScrib can generate trend summaries (e.g., attention, insight, risk) and succinct overviews for case conferences or discharge summaries.

7) Template Governance
Clinic admins can update templates (e.g., new risk prompts). AI highlights changes and nudges clinicians to adopt them.

8) Privacy & Segmentation
Sensitive notes can be segmented (e.g., psychotherapy-style reflections) with access controls, ensuring confidentiality.

Charts & Visuals

Chart 1: Average Time per MSE (Manual vs Template vs AI-Assisted)

Chart 2: Feature Comparison — Template Only vs DocScrib AI

(If you’d like, I can turn these tables into PNG/SVG charts in DocScrib’s navy-and-gold palette.)

Example MSE Write-Ups

Example 1: Psychiatric — Acute Depression with Auditory Hallucinations

Header
Patient: Ms. K (ID 556) | Date/Time: 11:30 AM | Clinician: Dr. Rao, Psychiatrist | Inpatient ward | Reason: Admission evaluation

Appearance & Behavior
Disheveled; poor hygiene; unkempt hair; slouched posture; limited eye contact.

Attitude / Rapport
Guarded initially; becomes cooperative with gentle prompts.

Speech
Slow rate, low volume, increased latency; minimal spontaneous elaboration; monotone prosody.

Mood & Affect
Mood (subjective): “Hopeless, empty.”
Affect: constricted, restricted range, congruent with mood; low reactivity.

Thought Process / Form
Coherent and linear but slowed; occasional blocking; no flight of ideas or loosening.

Thought Content
Auditory hallucinations: second-person critical voices, intermittent. No visual hallucinations. Passive suicidal ideation without plan or intent. Guilt and worthlessness present. No fixed delusional system elicited.

Perception
Auditory hallucinations as above; denies illusions; reality testing partially intact.

Cognition / Orientation / Memory / Attention
Oriented to person, place, time, and situation. Serial 7s with two errors; WORLD backwards correct. Immediate and recent memory intact; remote memory intact. Abstract reasoning fair; fund of knowledge appropriate.

Insight
Partial: acknowledges “something is wrong,” attributes to stress more than illness.

Judgment
Limited: ambivalent about treatment adherence; understands some consequences.

Risk / Safety
Passive suicidal ideation; no plan or intent; protective factors include family involvement and treatment engagement. Safety plan initiated; increased observation recommended.

Summary / Impressions
Major depressive episode with psychotic features. Cognitive functions preserved with psychomotor slowing. Insight limited; judgment compromised. Moderate self-harm risk; monitor closely and initiate treatment.

Signature / Timestamp
Dr. Rao, MD | Documentation completed same day

Example 2: Neurology / Neuropsychiatry — Suspected Delirium in Elderly Patient

Header
Patient: Mr. S (ID 1102) | Date/Time: 09:30 AM | Clinician: Dr. Patel, Neuropsychiatrist | Hospital ward | Reason: New-onset confusion

Appearance & Behavior
Elderly male; disheveled gown; distractible; intermittently staring; slumped posture.

Attitude / Rapport
Fluctuating cooperation; engagement alternates with drift into confusion.

Speech
Variable rate and volume; occasional slurring; tangential output; intermittent word-finding pauses.

Mood & Affect
Mood: “Confused.”
Affect: labile; swings from tearful to irritable; occasional incongruence.

Thought Process / Form
Disorganized; loose associations and derailment; tangential responses.

Thought Content
No consistent delusional system; intermittent suspiciousness. Denies self-harm. Limited reliability due to confusion.

Perception
Visual hallucinations of shadowy figures; transient illusions; auditory hallucinations denied.

Cognition / Orientation / Memory / Attention
Disoriented to date and place; attention severely impaired (cannot complete serial tasks); immediate and recent memory impaired; remote memory patchy; abstract reasoning poor; fund of knowledge below expected baseline.

Insight
Absent: does not recognize confusion as abnormal.

Judgment
Impaired: attempted unsupervised ambulation; poor hazard awareness.

Risk / Safety
High risk due to disorientation and wandering potential; continuous observation and environmental safety measures instituted.

Summary / Impressions
Acute confusional state consistent with delirium; significant cognitive impairment and thought disorganization; urgent risk management required; investigate reversible causes and treat precipitating factors.

Signature / Timestamp
Dr. Patel, MD | Documentation completed same day

Best Practices, Pitfalls & Tips

• Obtain consent for any recording or transcription in clinical settings.
• Use a hybrid approach: let the template guide, but allow narrative where nuance matters.
• Document negatives: specify absent delusions/hallucinations or intact cognition to show you assessed.
• Be objective and specific: avoid vague descriptors; favor observable behavior and measurable performance.
• Include quotes judiciously when they clarify thought content or risk.
• Always document risk when safety concerns arise, including protective factors and actions taken.
• Cross-check consistency across domains (e.g., hallucinations in content matched in perception).
• Compare with prior MSEs to track change.
• Use cognitive screens within the cognition domain when clinically indicated.
• Practice cultural humility in interpreting eye contact, expressivity, or affect norms.
• Write promptly after the encounter to preserve detail.
• Maintain audit trails and timestamps for quality and defensibility.

Conclusion

The Mental State Examination is foundational for psychiatric and mental health care. A strong MSE blends careful observation with structured reporting and clear, objective language. Templates provide consistency and reduce omissions; when paired with DocScrib’s AI, clinicians gain speed, consistency, and smart safety checks—without losing the clinical nuance that makes MSEs valuable.

By adopting DocScrib MSE Templates with AI assistance, teams can streamline documentation, support quality and safety, and spend more time where it matters most: with patients.

Experience streamlined, AI-assisted MSE documentation with DocScrib.
Book a free demo today and see how structured templates plus AI support can transform your workflow.