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Documentation aid

Mental status exam quick reference

A one-page educational reference to the domains of the mental status exam, with example descriptors. For documentation and teaching, not a diagnostic tool.

Download the PDFPDF, 1 page, 4 KB. Free, no sign-up. For clinicians.
Educational example only. This is not legal, medical, or compliance advice, and it is not a ready-to-use legal document. Requirements vary by state, payer, and setting. Adapt anything like this to your own situation and have it reviewed by qualified legal and compliance counsel licensed in your jurisdiction before using it in a practice. You are responsible for compliance with all applicable federal and state laws, including HIPAA. shrinkiatry publishes professional commentary and education, not legal or medical advice.

Current as of July 7, 2026. Laws, payer rules, and billing codes change, so confirm the current requirements for your jurisdiction and setting before you rely on it.

What's inside

Domains and example descriptors

  • Appearance: grooming, dress, apparent age
  • Behavior and psychomotor: cooperative, restless, slowed, agitated
  • Speech: rate, volume, prosody, latency
  • Mood: the patient's stated feeling, in quotes
  • Affect: range, congruence, and reactivity
  • Thought process: linear, tangential, circumstantial, disorganized
  • Thought content: preoccupations, obsessions, delusions, and safety (suicidal or homicidal ideation)
  • Perception: hallucinations or none reported
  • Cognition: alertness, orientation, attention, memory
  • Insight and judgment: intact, limited, or poor, with a reason

Note

Describe what you observe in plain, specific language, and always document a safety assessment when indicated. Crisis line: call or text 988 in the US.

About this resource

This reference is part of the shrinkiatry resource library, a set of free, clinician-facing references and examples. It's reviewed by Shariq Refai, MD, MBA, FAPA, a board-certified psychiatrist, on a quarterly schedule. Next scheduled review: October 1, 2026. First published July 7, 2026, last reviewed July 7, 2026.

Browse the rest of the resource library, or verify who reviews this site. Spotted something out of date? Email corrections@shrinkiatry.com.

Educational and professional commentary only. shrinkiatry explains the profession of psychiatry. It doesn't provide medical advice, isn't a substitute for evaluation or treatment by a licensed clinician, and reading it doesn't create a doctor-patient relationship.