Chamberlain College of Nursing NR320/326

Mental Status Examination Directions and Grading

Purpose: The primary purpose of the Mental Status Examination (MSE) is to gather more objective
data to be used in determining etiology, diagnosis, prognosis, and treatment. It is a description of the
client’s mental functioning in all applicable areas.

Due Date: To be determined by your clinical instructor.

Total Points: 50

I. Assignment Criteria
II. MSE Template
III. Grading Scheme

I. Assignment Criteria

Presenting Problem:
Describe in detail specific causative factors that led to hospitalization including chief complaint,
development and duration of problem or any other factors that contribute to the understanding of this
client. i.e. educational level, employment, family composition.

Appearance and Behavior:

Observable characteristic of a person (objective data), such as:
 Facial expression: (calm, perplexed, stressed, tense, sad or depressed)
 Gestures, posture: (relaxed, tense, erect, slouching).
 Dress: (neat, unkempt, eccentric). Describe what client is wearing.
 Physical characteristics: (anything that is unusual or stands out).
 Motor activity: (agitation, restlessness, tremors, motor retardation); apraxia, akathisia,
dyskinesia, parkinsonian movement.

Speech and communication:

How the client is communicating, rather than what the client is telling you. Rate, volume,
modulation, and flow of speech.

Affect or mood:
Affect: inappropriate, euphoria, depression, labile, depression, anxiety. Suicide: plan, means,
contract for safety, history of suicide attempts.

Thinking:
Disturbances in thought process: loose associations, circumstantialities, tangentiality, flight of
ideas, preservation, blocking, ideas of reference.

Disturbances in thought content: delusion, preoccupation of thought, phobia. (Describe

identified content).

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Chamberlain College of Nursing NR320/326

Other disturbances in thought or memory: amnesia, confabulation, capacity for abstract

thinking.

Perception:
Hallucinations, illusions, depersonalization, de-realization. (Describe specified nature of
disturbance).

Memory:
Recent, remote.

Judgment:
Ability to solve problems and make decisions

Insight:
Awareness of one’s own responsibilities and concerns, especially regarding this illness; a
person’s ability to analyze the problem objectively.

Summary of client:
Complete a summary of your client.

Standard English grammar, punctuation, word usage and complete sentences required.

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Chamberlain College of Nursing NR320/326

Student: _______________________________________________________ Date: ___________

Mental Status Exam

Client’s initials: ______ Age:______ Gender: ______ Race/Culture: _________________________

Write a descriptive paragraph of each major category below.

Presenting Problem:

Appearance and Behavior:

Speech and communication:

Affect or mood:

Thinking:

Perception:

Memory:

Judgment:

Insight:

Summary of client:

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Chamberlain College of Nursing NR320/326

III. Grading Scheme

Presenting Problem: 5 points

Appearance and Behavior: 5 points

Speech and communication: 5 points

Affect or mood: 5 points

Thinking: 5 points

Perception: 5 points

Memory: 5 points

Judgment: 5 points

Insight: 5 points

Rules of standard English observed: 5 points

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