Estimated reading time at 200 wpm: 21 minutes
The mental state examination sits at the heart of psychiatric practice. It is both a clinical skill and a professional responsibility. Yet it remains one of the most poorly executed aspects of psychiatric assessment across all levels of experience. Persons in higher management would do well to study this article, to better understand the time involved in both carrying out a proper MSE and in proper documentation of it. In January 2012, I touched on Mental State Examination (MSE) rather briefly. I pointed out an example of what is a substandard MSE.
The fundamental issue is simple: clinicians often write opinions in MSE instead of observations. They document conclusions rather than evidence. They use shorthand that obscures rather than clarifies. Shortcuts and shorthand usually signify extreme service pressures. Short-changing patient care is a good way to deliver poor quality care while ticking a tick-box.
Whether or not you agree our Fat Disclaimer applies
A mental state examination that states “patient appears depressed with poor self-care” tells us almost nothing. It represents the assessor’s conclusion but provides no data to support it. Another clinician reading these notes cannot form their own view. A court cannot scrutinise the evidence. A colleague taking over care has no baseline for comparison.
This matters profoundly. Mental state examination provides the factual foundation for diagnosis, risk assessment, and treatment planning. When that foundation is weak, everything built upon it becomes questionable.
A few general statements first.
In General
- MSE is important.
- Not all patients will give full access to their mental state.
- A very important part of the MSE is based on observations of the patient. (Even with ‘physical examinations’, observation was always a big part of the activity).
- Non-cooperation does not mean that a MSE cannot be performed.
- Observation requires no consent – because it is what everybody can see without seeking permission. Normally though, a psychiatrist or other health professional, will inform the patient of an examination and seek consent.
- Anything that limited the extent or reliability of the MSE must be stated. This is not just about court reports. It is sound clinical practice.
- Careful documentation of the MSE is absolutely essential.
- Assessors should record all relevant verbal and non-verbal findings.
What We Actually Do
A robust mental state examination requires us to document what we observe through our senses. What did the person look like when they walked into the room? How were they dressed? Was there an odour? How did they sit? Where did they direct their gaze? These are observable facts that anyone present could verify.
When we move to speech, we quantify. Not “slow speech” but “pauses of 10-15 seconds between question and response.” Not “quiet voice” but “I had to lean forward and ask him to repeat himself twice in the first five minutes.” These details paint a picture and provide measurable data.
The assessment of mood demands particular care. Mood is not a momentary feeling captured by asking “how do you feel right now?” It represents the sustained emotional and biological state over weeks. The season, not the weather. We must systematically explore sleep patterns, energy levels, appetite and weight, interest and enjoyment, guilt, concentration, and outlook. We document what the person tells us in their own words. “He said he wakes at 4am every morning and cannot return to sleep” provides evidence. “Early morning wakening present” provides a checklist tick.
Affect, by contrast, captures the observable emotional expression during the assessment itself. Not the conclusion “flat affect” but the evidence: “His facial expression remained unchanged throughout. When he mentioned his children, his eyes briefly filled with tears but his face remained otherwise fixed and no tears fell.” This description allows readers to understand what “flat” meant in this specific instance.
The Question of Attribution
Throughout the assessment, we must be clear about the source of information. “He told me“, “he said“, “when I asked” – these phrases maintain transparency about what was observed versus what was reported. They remind us that we are documenting the person’s account alongside our observations. This becomes critical in medico-legal contexts where clarity about evidence sources is essential.
Direct quotes serve multiple purposes. They capture the person’s authentic voice. They provide powerful clinical evidence of severity. They demonstrate that we actually asked the questions and listened to the answers. A person who says “even getting dressed feels like climbing a mountain” conveys more than any clinical descriptor about their energy level.
Risk Assessment: No Shortcuts
If there is one area where detailed documentation is non-negotiable, it is risk assessment. “Passive suicidal ideation present” is professionally inadequate and potentially indefensible. We must document exactly what was asked and exactly what was said. The person’s response matters – did they pause before answering? Did they look up? What were their actual words? How frequent are these thoughts? At what times? What methods have they considered? Have they acquired means? Set a time?
This level of detail serves multiple purposes. It provides evidence for immediate risk formulation. It creates a baseline for monitoring change. It demonstrates that we took the assessment seriously. Most importantly, if something goes wrong, it shows we asked the right questions and documented the answers. The absence of such documentation is indefensible.
The Practical Reality
Time pressure is real. Clinicians work in overstretched services with competing demands. However, the choice is not between the robust mental state examination presented here and a superficial checklist. The poor mental state examination is not an efficient alternative – it is simply inadequate. It wastes the clinical encounter by failing to gather the data needed for decision-making. It often leads to repeated assessments by others trying to obtain missing information. It creates risk through incomplete documentation.
The robust approach takes more time to write but saves time overall. It provides comprehensive information for the team. It prevents misunderstandings and repetition. It stands up to scrutiny. Most importantly, it serves the person being assessed by ensuring their presentation is accurately recorded.
For trainees sitting examinations, there is a middle ground. Demonstrate systematic assessment. Use some quantification. Include key direct quotes. Show observational skills. Always document risk in detail. This efficient thoroughness is different from superficiality. After qualification, develop towards the comprehensive standard required for real clinical practice.
The Professional Standard
Every profession has standards for documentation. In psychiatry, the mental state examination represents our equivalent of the physical examination. It must be done properly. This means:
- Recording observations, not just conclusions
- Using the person’s own words frequently
- Quantifying wherever possible
- Maintaining clear attribution
- Documenting systematically across all domains
- Providing sufficient detail for others to form their own clinical view
- Creating a factual record that can withstand scrutiny
These are not aspirational ideals. They are basic professional requirements. To avoid stress do not read the General Medical Council’s expectations that are relevant to proper examination and documentation.
Comparisons of Robust v Poor MSE
Note there are three clickable tabs below
Mental State Examination – Poor Example
Patient: Mr X Age: 44 years Date of assessment: [Date] Duration of assessment: 5 minutes
Appearance and Behaviour
Patient appears depressed. Poor self-care noted. Appropriate dress for weather. Limited eye contact throughout interview. Cooperative with assessment.
Speech
Slow speech with long pauses.
Mood
Patient reports low mood for several months. Subjectively “empty”, objectively depressed.
Multiple biological symptoms of depression present including early morning wakening, low energy, poor appetite with significant weight loss, anhedonia, guilt, poor concentration.
Diurnal variation not apparent.
Affect
Flat affect, congruent with low mood.
Thoughts
No formal thought disorder.
Depressive cognitions present – feelings of worthlessness and hopelessness noted.
Passive suicidal ideation present. No active plans or intent. Denies homicidal ideation.
Perception
No hallucinations or abnormal perceptions reported.
Cognition
Oriented to time, place and person. Concentration impaired.
Insight
Good insight into mental illness. Agrees needs treatment.
Mental State Examination
Patient: Mr X Age: 44 years Date of assessment: [Date] Duration of assessment: 40 minutes
Appearance and Behaviour
Mr X is a 44-year-old white male who appeared older than his stated age. He walked slowly into the room with a stooped posture, shoulders rounded forward. His gait was heavy and appeared effortful.
He wore a grey tracksuit with visible stains on the front of the top. The tracksuit appeared creased, as if it had been slept in. His hair was greasy and uncombed, approximately 2-3cm in length, with patches sticking up at odd angles. He had 4-5 days of unshaven stubble growth, patchy and unkempt. His fingernails had visible grime underneath them. There was a musty, unwashed smell noticeable when sitting within 1-2 metres of him.
He sat heavily in the chair, slumping backwards with arms folded across his chest. He remained in this position throughout the 40-minute assessment without shifting his posture. His eye contact was minimal. He looked at me briefly when first entering the room, then fixed his gaze downward at the floor for the remainder of the assessment. When speaking, he occasionally glanced up for 1-2 seconds before returning his gaze to the floor.
Speech
His speech was quiet. I had to lean forward and ask him to repeat himself twice in the first five minutes. The volume remained consistently low throughout the assessment.
The rate of his speech was markedly slow with pauses of 5-15 seconds between my questions and his responses. Some pauses extended to 20-25 seconds before he began speaking. His tone was flat and monotonous throughout.
Mood
When I asked how he had been feeling over the past few weeks, he paused for approximately 15 seconds, then said “empty… just empty” in a flat tone. He told me this had been constant, stating it had been “the same for months now, since about March.”
Sleep: He said he wakes at 4am every morning and cannot return to sleep. He told me he lies in bed until around 8am. He said he has no difficulty getting to sleep initially. He reported this pattern has been present for “two or three months.”
Energy: He said he has “no energy at all” and told me “even getting dressed feels like climbing a mountain.” He reported spending most of the day sitting or lying down. He said there are no periods during the day when his energy improves.
Appetite and weight: He told me his appetite has gone. He said “I have to force myself to eat.” He reported that his wife prepares meals but he “can only manage a few mouthfuls.” He estimated his food intake as perhaps one small meal per day. He said he has lost approximately two stone in weight over three months. His clothing appeared loose-fitting on him.
Interest and enjoyment: He told me he has lost all interest in things he used to enjoy. He said he used to play golf weekly but “hasn’t picked up the clubs in months.” He said he watches television but “I’m not really watching it, just staring at the screen.” He told me nothing gives him pleasure anymore.
Guilt: He said “I’ve failed everyone” and “this is all my fault.” When I asked him to elaborate, he struggled to provide specific examples but repeatedly said he was “useless” and “a burden.”
Concentration: He told me his concentration has gone. He said “I can’t follow anything” and reported being unable to read more than a paragraph before “losing track.” He said he takes a long time to make simple decisions, such as what to wear.
Outlook: He said “there’s no point to any of it” when discussing the future. He told me he cannot see things improving.
Rating: When I asked him to rate his mood over this period out of 10, he said “two, maybe one” after another long pause. He told me there have been no better days.
Affect
His facial expression remained fixed throughout the assessment. His brow was slightly furrowed and the corners of his mouth turned down. There was no variation in his expression. When discussing neutral topics his expression did not change. When he mentioned his children, his eyes briefly filled with tears but his facial expression remained otherwise unchanged and no tears fell. His voice remained monotone throughout with no inflection. The range of his affect appeared restricted. His affect appeared congruent with his subjectively low mood.
Thoughts
Thought form: He answered questions relevantly, though slowly. There was no evidence of thought disorder, loosening of associations, or tangential thinking.
Thought content: He repeatedly returned to themes of worthlessness. He stated “I’ve let everyone down” and “they’d be better off without me.” When I asked him to elaborate, he said “my wife does everything now, the kids… I can’t even get myself dressed some days.” He described himself as “a burden” three times during the assessment. He stated “there’s no point to any of it” when discussing the future.
Suicidal thoughts: When I asked him directly about thoughts of self-harm, he paused for approximately 20 seconds, looked up briefly, then said “yeah, I think about it.” He told me he has thoughts of not waking up, occurring “most days, especially in the morning.” When I asked about active plans, he said “I’ve thought about taking tablets, all of them” but told me he has not acquired any means and has not set a specific time. He said he has not thought about harming others.
Perception
On my inquiry, he told me he does not hear sounds or voices that other people cannot hear. He said he does not see things that others do not see. He denied experiencing unusual smells or tastes. When I asked him specifically about these experiences, he shook his head and said “no, nothing like that.”
Cognition
It was not appropriate in is obvious difficulties to carry out a full cognitive assessment. He correctly stated today’s date, the day of the week, his current location, and his full name and date of birth without hesitation. He did not recall my name, though I reminded him at 10 minutes before our interview ended.
Insight
When I asked him if he thought he was unwell, he nodded and said “I know something’s wrong, I can’t go on like this.” He told me “it’s depression again” when I asked what he thought the problem was. He said he needs help, stating “I need something to change.” When I discussed the possibility of hospital admission, he said “I don’t know… maybe.”
| Aspect | Poor MSE | Robust MSE |
|---|---|---|
| Length | Very brief – fits on less than one page | Detailed – approximately 3 pages |
| Direct quotes | 1 quote (“empty”) | Multiple quotes throughout every section |
| Duration | 5 minutes [no time spent with rapport, compassion or empathy] | 40 minutes [clearly invested in rapport, compassion and empathy] |
| Quantification | Minimal (none for pauses, weight, time) | Extensive (pause duration, weight loss, timeline, frequency) |
| Attribution | Rare – uses passive voice (“noted”, “reported”) | Consistent – uses “He said”, “He told me”, “When I asked” |
| Observable details | Few – mostly conclusions | Rich – specific descriptions throughout |
| Time markers | None | Assessment duration noted, pause timings, temporal patterns documented |
| Evidence vs Opinion | Heavy on opinion and conclusions | Heavy on evidence and observations |
| Risk assessment | Inadequate – 2 sentences | Comprehensive – detailed questioning documented |
| Baseline data | Minimal – cannot measure change | Extensive – clear baseline for monitoring |
| Medico-legal fitness | It’s a magnet for the Coroner’s excavations! | Would withstand detailed scrutiny. Coroner friendly. |
| Clinical utility | Low – colleague would need to repeat assessment | High – provides comprehensive picture |
| Professional standard | Below acceptable | Meets professional standard |
What Makes Documentation Poor:
- Conclusions instead of observations (“appears depressed”, “objectively low”)
- Vague descriptions (“poor self-care”, “limited eye contact”)
- Missing quantification (how long? how much? how often?)
- Lack of attribution (who said what?)
- Absence of direct quotes (patient’s voice not heard)
- Checklist mentality (symptoms listed but not explored)
- Jargon without evidence (“passive suicidal ideation”)
- Inadequate risk documentation (medico-legally dangerous)
What Makes Documentation Robust:
- Specific observable details (what you saw, heard, smelled)
- Quantification throughout (durations, frequencies, measurements)
- Consistent attribution (clear who said what)
- Multiple direct quotes (patient’s own words)
- Systematic exploration (each domain covered properly)
- Temporal markers (when things occurred during assessment)
- Observable confirmations (loose clothes confirming weight loss)
- Evidence-based conclusions (congruence stated after evidence presented)
The Bottom Line
The robust MSE takes longer to write but provides immeasurably greater value. It serves the patient, the team, the organisation, and stands up to scrutiny. Most importantly, it documents what was actually observed and said, allowing transparency and accountability in clinical decision-making.
Time Considerations
Common defence: “I don’t have time to write detailed notes“. If you’re foolish enough, tell that to the Coroner or the GMC. You have choice.
Reality check:
- Robust MSE may vary from case to case but usually takes over 15 minutes in clinical work. It may require more time for new patients with depression and where risk of suicide emerges.
- Writing detailed notes takes longer but quality difference is enormous.
- Poor documentation leads to repeated assessments by others gathering missing information – wastes more time overall.
- In medico-legal cases, inadequate documentation leads to lengthy reconstruction attempts – far more time-consuming than writing properly initially.
- Risk: inadequate documentation of suicidal thoughts could be indefensible if patient comes to harm.
Professional obligation: Every MSE should aim for the robust standard.
Some specifics
- The MSE is partly opinions formed by the assessor i.e. observations are rarely made without forming opinions. For example, “I observed a bad odour coming from the direction of the patient as he entered the room“, is an opinion and also an observation. The word ‘bad’ is partly opinion. Note that an opinion-observation about body-odour, is determined at a later stage e.g. “The patient was malodorous. There was no other explanation for the bad odour in the room.” OR – “The patient appeared to be drowsy and unsteady on his feet.” – are opinions as well as observations. Expert assessors for courts are allowed to give such opinion evidence. Who is an expert, is a separate matter.
- Whilst opinion-observations are allowed, assessors need to stick very close to facts. A fact is what any reasonable person would observe; not simply what ‘an expert’ would observe. An expert-opinion-observation is more qualified in nature but that does not mean ‘fact’. If assessors state (for example), “He appeared to be thought disordered“, it is important to record what was said to confirm that opinion-observation. ‘What was said’, is not an interpretation of what was said. It is the actual words of the interviewee. This means that interviewers ought to make significant notes of snippets of verbatim as far as practicable.
- The comprehensive scope of the MSE is so wide and deep, it is important for assessors to report things that were not found or observed. These become important for others to understand how diagnoses were made or ruled out.
Important Note: Clinical Examinations Context
For MRCPsych and Similar Clinical Exams
The robust MSE presented here represents the gold standard for real-world clinical practice, particularly in forensic psychiatry, medico-legal work, and situations requiring detailed documentation. However, candidates sitting clinical examinations face different constraints.
In examination settings (e.g., MRCPsych CASC, OSCEs):
Candidates typically have:
- Limited time (often 5-10 minutes for MSE within a longer station)
- Multiple tasks to complete (history, MSE, formulation, management plan)
- Need to demonstrate competence across all domains efficiently
Practical examination approach:
- Prioritise systematically – cover all ASEPTIC domains but with appropriate brevity
- Focus on pertinent positives and negatives – document what’s clinically significant
- Use some quantification – but be selective (e.g., “pauses of 10-15 seconds” rather than documenting every pause)
- Include key direct quotes – 1-2 powerful quotes showing severity rather than multiple quotes
- Demonstrate observational skills – mention at least one olfactory, postural, or grooming detail
- Risk assessment must remain detailed – never compromise on documenting suicidal thoughts
- Show attribution – use “he said”, “he told me” even in briefer format
Example of efficient exam-appropriate documentation:
“His speech was quiet with marked slowing and pauses of 10-15 seconds before responding. When asked about mood over recent weeks, he said ’empty’ and described this as constant for three months. He reported early morning wakening at 4am, no energy (‘even getting dressed feels like climbing a mountain’), poor appetite with two stone weight loss, loss of interest in golf which he previously enjoyed weekly, and guilt stating ‘I’ve failed everyone.’ When asked about suicidal thoughts, he paused approximately 20 seconds then said ‘yeah, I think about it’ – thoughts of not waking occurring most days, especially mornings. He has thought about overdose but denied acquiring means or setting a time.”
This efficient version:
- ✅ Demonstrates systematic exploration
- ✅ Includes quantification
- ✅ Contains powerful direct quotes
- ✅ Shows attribution
- ✅ Documents risk appropriately
- ✅ Can be completed within exam time constraints
The key distinction:
- In exams: Demonstrate competent, systematic assessment within time limits
- In real clinical practice: Document comprehensively for clinical, legal, and professional purposes
- The poor MSE fails in BOTH contexts – it’s neither efficient (wastes opportunity to gather data) nor thorough (provides no useful detail)
Bottom line for exam candidates: Aim for efficient thoroughness, not the poor MSE’s superficiality. Practice documenting key observations with some direct quotes and quantification. Risk assessment always requires detail. After qualification, develop towards the robust standard for real-world practice.
What MSE Means for Practice
For consultants, this means expecting and modelling high standards. The rushed, opinion-heavy mental state examination should not be accepted as adequate. Trainees learn by example. If they see seniors cutting corners, they will do the same.
For trainees, this means developing good habits from the start. The additional effort required to document properly becomes automatic with practice. The discipline of writing observations rather than opinions improves clinical thinking. The habit of using direct quotes sharpens listening skills.
For services, this means recognising that adequate time for assessment and documentation is not a luxury. It is a necessity for safe, effective, defensible practice.
The Medico-Legal Dimension
Forensic psychiatrists understand this implicitly. Courts and Tribunals need to know that there is a foundation of evidence. Expert evidence (i.e. expert opinion) follows from the evidence gathered and must be justified by it. A report stating “the patient appeared depressed” would be challenged immediately. What was actually observed? What was said? How did you reach that conclusion?
But this standard should not be reserved for forensic work. Every psychiatric assessment carries potential legal implications. Mental Health Act assessments. Capacity evaluations. Risk decisions. Employment reports. Disability assessments. In any of these contexts, inadequate documentation creates problems. The mental state examination must provide a factual foundation that can be examined and understood by others.
The Path Forward
Improving mental state examination documentation requires several things:
First, awareness that the current standard is often inadequate. Many clinicians genuinely believe their brief, opinion-heavy notes are sufficient. They need to see the difference between superficial and robust documentation.
Second, teaching and supervision focused on this skill. Medical education tends to emphasise diagnosis and treatment more than documentation. Yet documentation is fundamental. Poor documentation undermines everything else.
Third, protected time for proper assessment. Services that demand clinicians see excessive numbers of patients while maintaining high documentation standards create impossible tensions. Something has to give, and it is usually documentation quality.
Fourth, peer review and feedback. Clinicians should regularly review each other’s mental state examinations and provide constructive feedback. This creates accountability and drives improvement.
Fifth, recognition that this matters. Mental state examination documentation is not administrative burden. It is core clinical practice that directly affects patient care and safety.
Final Thoughts
The mental state examination is simultaneously simple and complex. Simple in concept – observe and record what you see and hear. Complex in execution – doing this thoroughly and accurately takes skill, time, and discipline.
The difference between poor and robust documentation is not subtle. One provides conclusions without evidence. The other provides rich, detailed observations that allow independent evaluation. One would fail under scrutiny. The other would withstand detailed examination.
Every psychiatrist should be capable of producing robust mental state examinations. This is not about being forensic specialists or having particular expertise. It is about meeting basic professional standards for clinical documentation.
The person sitting opposite us deserves to have their presentation accurately recorded. Our colleagues deserve clear information for continuing care. Our organisations deserve defensible documentation. The profession deserves to maintain standards. Most importantly, proper documentation serves patient safety by ensuring clinical decision-making is transparent, evidence-based, and accountable.
The mental state examination is not a bureaucratic exercise. It is a clinical skill that captures a moment in time in another person’s mental life. Do it properly. Document what you observe. Record what they say. Provide evidence, not just opinion. Create a factual record that serves everyone who needs to understand this person’s presentation.
Never provoke the Coroner.
That is the standard we should all aim for. That is the standard our patients deserve.
