In order to keep track and analyze a mental health patient’s condition, a medical examiner who has a specialty in psychology and mental health should prepare a mental status examination report as it is crucial, especially in conducting a thorough review of a patient’s psychological condition. Are you a person who aspires to be a psychiatrist? One of the things you need to consider is being able to create a comprehensive mental status examination report. In this article, we will discuss beneficial steps in writing your medical report, plus several downloadable medical report templates for you to use. Keep on reading!

FREE 10+ Mental Status Examination Report Samples

1. Mini-Mental State Examination Report

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  • PDF

Size: 34 KB

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2. Mental Status Examination Rapid Record Report

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  • PDF

Size: 41 KB

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3. Mental Status Software Evaluation Report

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  • PDF

Size: 43 KB

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4. Standardized Mini-Mental State Examination Report

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  • PDF

Size: 262 KB

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5. Mental Status Examination Physician Report

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  • PDF

Size: 117 KB

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4. Mental Status Exam Checklist Report

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  • PDF

Size: 50 KB

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5. Mental Status Practice Exam Report

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  • PDF

Size: 314 KB

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6. Mental Health Status Examination Report

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  • PDF

Size: 181 KB

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7. Mental Status Evaluation Report

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  • PDF

Size: 208 KB

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8. Mental Status Psychological Examination Report

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  • PDF

Size: 76 KB

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9. Mental Status Client Examination Report

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  • PDF

Size: 181 KB

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10. Patient Mini-Mental State Examination Report

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  • PDF

Size: 23 KB

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11. Mental Status Medical Examination Report

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  • DOC

Size: 20 KB

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What is a Mental Status Examination Report?

A mental status examination report is a useful piece of professional documents and medical report that contains well-detailed descriptions of a patient’s mental health condition. It comprises several observations, analyses, and examinations according to a patient’s appearance, emotion, cognition, and thinking. 

A mental health professional like a psychologist, psychiatrist, or mental health therapist carefully evaluates a person’s appearance, speech, behavior, cooperativeness, thought process, though content, perceptions, mood and affect, mind orientation, memory, insight, and judgment. Then, the doctor writes the medical test result or medical examiner report concerning the patient’s mental state.

How to Create a Mental Status Examination Report  

Creating a clear, well-detailed, and full mental status examination or psychological report is helpful while formulating a diagnosis for your patient and documenting his or her progress while undergoing psychological therapy or mental health treatment sessions. So, you need to use direct words and clear sentences while explaining the status of your patient’s mental health. 

In this matter, we suggest that you follow the steps below while freely using one of our medical report templates in this article:

1. Observe and evaluate your patient’s appearance, behavior, and attitude

One of the main aspects that you need to consider in creating a mental status examination report is observe and make an analysis of the overall appearance, behavior, and attitude of your patient. The book “The Neuropsychiatric Mental Status Examination” explained that as all the patient’s behaviors are essential for consideration in the mental status examination, the patient’s general appearance is the first behavioral area to be evaluated. 

2. Ask questions and implement actions

Your examination questions and actions you implement must proceed in a logical pattern yet maintain responsiveness to the particular needs of your patient. Be consistent and make sure that your patient feels safe and comfortable during the psychological examination.

3. Use a thorough evaluation or assessment of cognitive function 

The next step you must do to have a well-detailed mental status examination report is use a thorough evaluation test or method in measuring your patient’s cognitive abilities. Cognitive ability assessments evaluate how well individuals use an extensive range of mental processes like reading comprehension, solving  mathematical problems, abstract thinking, and learning ability.

4. Formulate a diagnosis

Describe your patient’s current state of mind and formulate a diagnosis based on history, examination, and investigation. Mental health practitioners and psychiatrists will observe a patient’s experiences of certain feelings, and behaviors, the duration of time he or she has been experiencing these things, and the impact it has on the patient’s life.

FAQ

What are the main components of a mental status exam?

A mental status exam should provide the appearance and general behavior of the patient. Include his or her consciousness and attentiveness level, motor and speech activity, mood, thought and perception, attitude and insight, and higher cognitive skills. 

What is the 30 question cognitive test?

It is usually called a mini-mental state examination or Folstein test which is being widely used in various clinical and research settings in measuring if a person has cognitive impairment. 

What are different types of mental health disorders?

The types of mental health disorders are anxiety disorders, personality disorders, eating disorders, mood disorders like depression or bipolar disorder, psychotic disorders like schizophrenia, post-traumatic stress disorder, and many more.

What are the common signs of mental illness?

Some common signs of mental illness are extremely high and low moods, excessive fear, worry or anxiety, social withdrawal, long-lasting sadness or irritability, and sudden changes in eating or sleeping habits.

Therefore, you need to have the skills and expertise in demonstrating and interpreting data for psychotherapy patients. Despite experiencing some hardships in conducting several mental health examinations, as well as treating your patients’ mental health disorders, you can be confident in writing a good mental status examination report. You just need to follow the aforementioned steps in this article. So, you can select from our diverse selection of examination report templates here and get a report sample today! 

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