Sacred Heart College

COLLEGE OF NURSING
Lucena City

MENTAL STATUS EXAMINATION

Instruction: Complete the MSE form based on your psychiatric assessment to your client. Please write in paragraph form and
include the specific verbalization of the client.

Name of Client: Date of Examination:

Diagnosis: (Based on DSM 5, including the Axis)

I. General Description (In paragraph form)

A. Demographic Data/History:

B. General Appearance:

C. Motor Behavior:

D. Attitude Toward the Examiner:

Assessment Parameters Findings/ Description/Statement Justification/Explanation

II. Emotion
A. Mood:
B. Affect:
C. Appropriateness
of Affect:

III. Speech:

SHCCN Template: Mental Status Examination Abundabar, F.

 Sacred Heart College
COLLEGE OF NURSING
Lucena City

IV. Perceptual
Disturbances:

V. Thought:

A. Process/Form of
Thought
B. Content of
Thought:

VI. Consciousness,
Sensorium, and
Cognition:
A. Alertness and
level of
consciousness
B. Orientation
C. Memory
D. Concentration
and Attention
E. Capacity to Read
and Write

VII. Judgment:

VIII. Insight:

SHCCN Template: Mental Status Examination Abundabar, F.

 Sacred Heart College
COLLEGE OF NURSING
Lucena City

Mental Status Examination (MSE)Rubric

Parameters Poor Fair Good Excellent Score

( 1-3 pts.) ( 4-6 pts.) ( 7-9 pts.) (10 pts.)
Attention to MSE Student did not Student fairly Student discussed all Student completely
Components adequately address discussed the main the components of discussed the
the main components of MSE the MSE but lacks components of MSE
components of the but lacks major relevant data to supported by
MSE. evidences/supporting support the findings. relevant data and
data. justification.
Use of Clinical Student did not Student utilized Student utilized Student incorporated
Terminology utilize or appropriate appropriate but very appropriate but appropriate and
clinical terminology limited clinical incomplete clinical clinical
in discussing the terminologies in terminologies in terminologies in
findings. discussing the discussing the discussing the
findings. findings. findings.
Overall Presentation was too Presentation was Presentation was Presentation was
Presentation brief, with short, with some somewhat complete, complete with
grammatical errors, grammatical errors, with minimal details, no
poor sentence fair sentence grammatical error, grammatical errors,
structure; and lacks structure, and lacks with good sentence with excellent
in-depth analysis. in-depth structure, and sentence structure,
analysis/justification included in-depth and showed in-depth
or explanation. analysis or analysis and
explanation. explanation for each
component.
TOTAL =

SHCCN Template: Mental Status Examination Abundabar, F.

 Sacred Heart College
COLLEGE OF NURSING
Lucena City

SHCCN Template: Mental Status Examination Abundabar, F.