Mental Status Exam Report Sample.

Note: The brackets help to identify the specific area each paragraph addresses. You do not have to include this in your write-up (i.e., leave the bracketed material out).

[Appearance & Behavior] Susan C. is a 5’4” single White female of average weight. At the time of the interview, she had a pasty white complexion and several scars from adolescent acne. She presented herself in a cooperative, friendly manner during the interview, was appropriately dressed for the season, and answered questions in a direct fashion. Her eye contact was appropriate. Psychomotor activity was within normal limits as she moved comfortably during the interview. No atypical physical characteristics were noted. Her speech patterns and expressive/receptive language were within normal limits. No evidence of current drug or alcohol intoxication was observed.

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[Sensorium and Mental Ability] During the interview, Susan C. appeared alert and oriented x 4. While not formally assessed, she appears to have average to above average intelligence as evidenced by her vocabulary and reported GPA in college. There was no difficulty with questions assessing her recent or remote memory, or mathematical calculations. Some abstract thinking difficulty was observed in her difficulty describing what the difference was between a lie and a mistake.

[Thought] Susan displayed a logical, sequential, coherent flow of thought. No tangential thinking, flight of ideas, or looseness of associations were noted. Thought content appeared to be within normal limits. No evidence of hallucinations, delusions, paranoid ideation, or ruminations was apparent. No compulsions or obsessions were reported.

[Sensory Motor and Perceptual Processes] Sensory motor and perceptual processes appeared within normal limits. Susan C. was able to adequately duplicate the drawing of a clock. There was no evidence of fine motor tremor, auditory, or perceptual difficulties.

[Affect and Mood] During the interview, Susan displayed a moderately depressed affect. While eye contact was appropriate, she seldom smiled even when an amusing incident occurred while we were in the office. Her voice tone had monotone qualities and she often sighed during the interview. She verbalized feeling depressed since her recent miscarriage (3 weeks ago). No history of manic-like symptoms was reported. She denied suicidal and homicidal ideation. There was no evidence of a risk for violence or impulsivity. [Self-regulation] Susan C. displayed adequate impulse control and judgment. These interview qualities are consistent with her history.