Template library · Assessments & screeners
Standard Mental Status Exam template
Document observations across all standard MSE domains.
Full mental status examination
- 17 fields across 6 sections
- Included with MyWellOps
- Edit it, or save your own version
What’s in it
Assessment Details
- Client NameText
- Date of BirthDate
- Client ID / MRNText
- Date of AssessmentDate
- Clinician / CoachText
- Location / ModalityText
Appearance & Behavior
- Appearance, grooming, and hygieneText
- Motor activity and eye contactText
Speech & Mood
- Speech (rate, volume, fluency)Text
- Mood (client-reported) and affect (observed)Text
Thought Process & Content
- Thought process (linear, tangential, etc.)Text
- Thought content (delusions, obsessions, suicidal/homicidal ideation)Text
Perception & Cognition
- Hallucinations or perceptual disturbancesText
- Orientation, memory, attention/concentrationText
- Insight and judgmentText
Signatures
- Clinician SignatureSignature
- Date signed (clinician)Date
When to use it
Use an assessment at the start of work to set a baseline, then repeat it at review points so you and the client can see what has changed.
How it works in MyWellOps
- Pick it from Documents.
- Send it to the client to complete, or fill it in together during a session.
- Each completed copy is kept on the client’s record, so earlier results are there to compare.
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