What Are Some Common Elements of Mental Status Exam Forms?


Quick Answer

Mental status exam forms commonly include sections to assess the patient's physical appearance, behavior, speech, mood and affect, states University of California, San Diego School of Medicine. Other common assessments include those of the patient's thought processes, thought content, awareness of the environment, memory and judgment. Additionally, a mental status exam form may have sections on the patient's abilities to perform mathematical calculations and understand complex ideas.

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In the physical appearance section of a mental status exam, a health care provider, often a psychiatrist or neurologist, makes note of how the patient is dressed and if the patient appears well-groomed, explains UCSD School of Medicine. In the behavior section, the provider uses terms such as "agitated," "pleasant" and "cooperative" to describe how the patient is behaving and makes note of whether the behavior is appropriate for the situation. In the speech section, the provider indicates whether the patient is speaking using an appropriate volume and tone, and whether she is speaking an appropriate amount given the circumstances.

The mood section of a mental status exam form contains information on how the patient feels emotionally, describes UCSD School of Medicine. The provider may simply ask the patient to describe how she is feeling and then record her answer, along with the provider's input on whether her mood is appropriate for the situation. The affect section, by comparison, consists of the provider's assessment of how the patient appears emotionally. Common terms providers use to describe a patient's affect include "excitable," "flat" and "appropriate." A patient with a flat affect shows very limited emotional expression, such as with an immobile face and monotonous vocal tone, explains University of Washington School of Medicine.

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