The student, using the identified client for their Biopsychosocial Assessment assignment, is to write a Mental Status Examination. This assignment will be written using the guidelines below. While the student may not have access to the client to conduct an MSE directly, they are to use information from their time spent with them as well as embellish information to fully address the components of the MSE. This is to provide the student with the experience of writing an MSE.
Mental Status Examination Guidelines
The Mental Status Examination is often referred to as the psychological equivalent of a physical exam (House,2014). The Mental Status Examination (MSE) is a component of the biopsychosocial assessment. The purpose is to provide a snapshot of how the client presents to the social worker during the assessment process in several areas. Those areas include appearance, motor activity, memory, speech, mood, affect, thought content, thought process, perception, intellect, and insight.
Category |
Observation examples |
|
Appearance |
Groomed, unkempt, appropriate clothing, disheveled. What is being worn? Scars? Tattoos? Hair clean, combed? |
|
Speech |
Is the rate normal, pressured, circumstantial, tangential |
|
Attitude/behavior |
Calm, cooperative, agitated, aggressive |
|
Mood |
Euthymic, irritable, elevated, anxious, depressed |
|
Affect |
Constricted, normal, flat, labile, blunted congruent to mood. |
|
Thought process/content |
Logical, disorganized, delusions, hallucinations, obsessions/compulsions, Suicidal Ideation |
|
Orientation |
To time, place, and person |
|
Memory |
Able to recall remote, recent, and immediate events. An example of recent memory is to name, remember, recall and repeat the names of three items. |
|
Concentration |
Serial 7’s or 3’s. Follow a three-step direction |
|
Abstract thought |
Can the person interpret proverbs |
|
Insight/Judgment |
Have insight into their condition. Good judgment observed. |
|
Intellect |
Observed to be within normal limits |
The Mental Status Examination is written in a paragraph format of approximately 300–400 words. Here are some examples.
Additional Guidance
The video linked below can also be found in Week 3’s “Weekly Resources Section” it provides a more detailed walkthrough of the assignment guidlines.
- Video: Mental Status Examination Assignment Introduction (5:12 minutes | Transcript)
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