How to write a mental state examination

The eight domains, what belongs in each, and why the difference between what you observed and what you were told is the most important line in the note.

The mental state examination is the part of a psychiatric assessment that describes the person in front of you, now. Not their history, not their diagnosis, not what the referral said. What you observed and elicited during this contact.

It is also the part most often written badly. A history can be reconstructed later from collateral and old notes. An MSE cannot: it is a description of a moment, and if that moment is recorded vaguely it is gone. Six weeks on, at a tribunal or a serious incident review, "appeared unwell" tells nobody anything.

What the MSE is, and what it is not

The MSE is a structured description. It is deliberately atheoretical: it records phenomena, not explanations. "Thought form showed flight of ideas" is an MSE finding. "The patient is manic" is a diagnosis, and belongs in your formulation.

Holding that line is what makes the MSE useful to the next clinician. They can read your description and reach their own view. If you write conclusions instead of observations, they have to take your word for it, and if you were wrong the error propagates through the record for years.

The eight domains

The conventional structure runs in the order below. Some texts split or merge domains; the mnemonic ASEPTIC (Appearance, Speech, Emotion, Perception, Thought, Insight, Cognition) is common in UK teaching. The grouping matters less than covering all of it.

1. Appearance and behaviour

Everything visible before either of you speaks. Grooming and self-care, clothing and whether it suits the setting and the weather, physical signs, eye contact, psychomotor activity, abnormal movements, and how the person engaged with you. Note changes across the interview: someone who settles is telling you something different from someone who escalates.

2. Speech

How they spoke, not what they said. Rate, volume, quantity, fluency, tone. Content belongs under thought. The commonest error is smuggling content in here — "speech was paranoid" is a thought content finding wearing the wrong hat.

3. Mood

Subjective: what the person tells you about their emotional state, ideally in their own words, often with a self-rating out of ten. A direct quotation is frequently the single most useful line in the whole note.

4. Affect

Objective: the emotion you observed, its range, its stability, and whether it fitted what was being discussed. Mood and affect diverging is a finding in itself and should be stated deliberately rather than left for the reader to notice.

5. Thought

Two separate things, and they need separating on the page. Form is how thinking is organised — linear, circumstantial, tangential, flight of ideas, loosening of associations. Content is what the thinking is about — persecutory ideas, grandiosity, obsessions, thoughts of self-harm. Also record how firmly abnormal beliefs are held, because that is what separates an overvalued idea from a delusion.

6. Perception

Hallucinations by modality, illusions, depersonalisation and derealisation. Ask about each modality rather than assuming auditory. If something is present, get the detail: frequency, content, whose voice, and how distressing it is. Also record what you observed — whether the person appeared to respond to stimuli you could not perceive.

7. Cognition

Orientation, attention and concentration, memory. Bedside testing only, unless you administered a formal instrument, in which case name it and give the score. Say plainly when you did not test something.

8. Insight and judgement

Not all-or-nothing. A person can accept they are unwell without accepting the explanation, or accept treatment without accepting the diagnosis. Record what they accept, what they do not, and what follows from that for their care.

Why the order matters

The sequence runs from what needs no cooperation to what needs a great deal. You can describe appearance from across a room. You cannot assess insight without a conversation the person is willing to have.

This is not merely convention. It means that when an assessment ends early — the person walks out, or becomes too distressed to continue — you still have the earlier domains recorded. An MSE that covers appearance, behaviour and speech, and says plainly that the rest could not be assessed, is a useful document. One that jumps to insight and leaves everything else blank is not.

Separating what you saw from what you were told

Three sources feed into most assessments: what you observed, what the person told you, and what somebody else reported. They carry different weight and they must be distinguishable on the page.

The second version is longer and better. It tells the reader what you saw, what was reported by whom, and that the person disagrees. Every one of those is a separate fact, and in six weeks the disagreement may be the most important line in the note.

Recording what you did not assess

A silent gap in an MSE reads as a normal finding. Nobody intends this, and everybody does it. A note with no cognition section will be read as cognition being unremarkable, because that is the natural inference.

A worked example

Synthetic, and deliberately not a complete note — enough to show the register.

Notice what it does not do. It does not say "manic". It does not rate his risk. It describes, and leaves the conclusions to the formulation, where they can be argued with.

Six mistakes worth avoiding

1. Diagnosing in the MSE. "Appeared psychotic" is a conclusion. Describe what led you there.
2. Mixing speech and thought. Rate and volume are speech. Content is thought.
3. Omitting the quotation. A person's own words about their mood are more useful than any paraphrase, and cannot be disputed later.
4. Leaving conviction unrecorded. Whether a belief is held firmly or with doubt changes what it means and what follows.
5. Silent gaps. Say what you did not assess.
6. Loaded descriptors. "Aggressive", "agitated", "non-compliant" and similar carry documented bias. Describing the behaviour is more accurate and more useful.

The last of those has an evidence base that surprises most clinicians, and it is worth reading about separately.

Common questions