Specialty formats

Mental Status Exam

A structured MSE that can stand alone or be appended to another note.

Supports:Individual7 sections

What it is

A structured mental status exam that can stand on its own or sit alongside another note. Each domain gets its own section so nothing is skipped.

What Tidemend writes in each section. You can rename, reorder or adjust any of these in a custom template.

Appearance & Behavior
Grooming, dress, eye contact, psychomotor activity, cooperation.
Speech
Rate, volume, tone, fluency.
Mood & Affect
Self-reported mood (quote if possible) and observed affect: range, congruence, stability.
Thought Process & Content
Organization of thought; content including preoccupations, obsessions, delusions, SI/HI.
Perception
Hallucinations or perceptual disturbances, or their absence.
Cognition
Orientation, attention, memory.
Insight & Judgment
Awareness of difficulties and quality of decision-making.

Individual · fictional example

Adult appearing stated age, casually dressed and well groomed. Good eye contact. No psychomotor agitation or retardation. Cooperative.

Normal rate, volume and tone. Fluent and coherent.

Mood: “tired but okay.” Affect mildly constricted, congruent with stated mood, stable.

Linear and goal-directed. Content focused on work stress. No obsessions or delusions. Denied SI/HI.

Denied auditory or visual hallucinations; none observed.

Alert and oriented to person, place, time and situation. Attention and recent memory grossly intact.

Insight good; recognizes the link between stress and sleep. Judgment intact.

Fictional example written for illustration. It doesn’t describe a real person or session.

Record, dictate or type the session and get a draft in this format, ready to review, check and sign.