I’m Dr. Grace Wlasowicz and I’m a psychiatric Nurse Practitioner.
Nearly one in five American adults will experience some form of mental illness. Research shows 32% of all mental-health related physician visits from 2012-2014 were to primary care physicians.
Screening for common emotional and psychological disorders is important at every patient visit, but I often hear from my colleagues in primary care that there’s a need to better understand how to conduct a mental health assessment. What I frequently hear from NPs boils down to: “I don’t know how to take a bowl of symptoms and document it into a mental health assessment.” And often in primary care, you don’t have as much time as you’d like during the patient encounter.
Nurse practitioners are often on the frontlines of addressing mental health needs, and we must meet those needs adequately. To help you get started learning how to accurately conduct mental status exams, I’m going to give you some language and words to use to help document patient encounters in a clear manner.
I’m going to introduce the components of a mental status exam, why it’s important, and identify what may help you obtain, evaluate, and accurately describe and document findings for your patients.
So, What is the Mental Status Exam? The Mental Status Exam is an assessment of the patient’s behavioral and cognitive functioning that occurs before the use of screening tools. It consists of a relatively standardized approach and set of questions and observations, and it is an integral component of competence and/or capacity assessments. It includes descriptions of the patient’s appearance and general behavior, speech and motor activity, mood and affect, level of consciousness and attentiveness, thought and perceptions, attitude, insight and cognitive abilities.
Establishing rapport is the foundation of conducting a mental status exam. Welcoming the patient, stating the purpose of the evaluation, encouraging open communication, and acknowledging privacy and concerns can help establish rapport. These are well-known routines for nurse practitioners.
Conducting a Mental Status Exam starts when you enter the room. I usually start with open-ended questions, asking the patient what has brought them here and allowing them time to tell their story.
I have a template I like to follow to document the exam. First, I am looking at appearance, manner, eye contact, and motor activity. I note their appearance and how to describe it. What is the manner of dress: professional or casual? Is it appropriate for the season or not? Are they well-groomed? Do they look their stated age or younger?
Now, I consider how to document their attitude and manner. Is it as cooperative, pleasant, or engaged? Are they guarded, irritable, or sarcastic?
How is the eye contact? Good, fair, poor, or very poor? Is it steady or intermittent?
Unkempt appearance or mannerisms could be indicative of mental illness. I also observe the level of general motor activity during my interview with a patient. Are they accelerated or slowed down? Are there any abnormal movements to document? I document it if there are tics or tremors, or if the patient seems restless or slowed.
In my practice, I group speech and language sections of the Mental Status Exam with the thought process and thought content sections. Are they receptive to being interviewed? When describing speech, would you consider it normal? Consider the cadence or rate at which they are speaking: is it normal, rapid, or slow? Loud or low volume? Does their speech seem spontaneous, do they seem pressured to talk, or are they sparse with their words?
Now you want to describe their language with descriptive words. Is the patient easy to understand? Fluent or accented? Do they mumble or stutter, or have trouble finding their words?
Thought process and thought content can usually be uncovered in speech when we present open-ended questions. Patients must decide what to say, how to answer, how much detail to include, and how to connect and move on to other topics.
As a patient talks about what has brought them here and how they are feeling, consider how to describe their thought process and articulations, such as: goal-directed, logical, organized or disorganized, tangential or circumstantial. Are they evasive, coherent or incoherent, are their thoughts racing or word salad?
Considering what the patient talks about, their perception of experiences, and whether they experience delusions can help determine if there’s an immediate risk to a patient. Questions I may ask to assess thought content include:
- “Are there thoughts or images that you have a really difficult time getting out of your head?”
- “Do you have personal beliefs that are not shared by others?”
- “Do you ever see, hear, smell, taste and feel things that are not really there, such as voices or visions?” or
- “Does it ever seem like people are stealing your thoughts or inserting thoughts into your head?”
I am looking to describe if the patient has suicidal or homicidal ideations or not. Are there delusions, hallucinations, or somatic preoccupation to document? Are they experiencing hopelessness, helplessness, guilt, or ruminations?
Next is assessing feeling: This includes mood and affect. Mood is going to reflect subjective data the patient shares about their emotional feelings. Aspects of mood include quality or type of mood reactivity, intensity, duration, and reactivity.
Affect is objective data you observe about the patient externally, regarding how emotional response may change and range of emotions, stability, intensity and type over time. Consider if it seems within normal limits of mood state. Descriptors of affect may include euthymic, anxious, elevated, tearful, irritable or angry, neutral or flat, depressed, constricted, among others.
Questions you can ask include “How have you been feeling lately? How would you describe your mood now?” ,“How would you describe your mood over the last two weeks?”
Keep in mind the interview requires multiple evaluations and observations over time, and patients in acute distress are generally unable to tolerate lengthy interviews at first meeting.
Next let’s look at how to document cognitive functions, insight and judgment.
At this point, if the patient is able to continue, I would perform a mini-mental status exam that takes 5-10 minutes to help assess cognitive function.
Consider attention and concentration: Would you describe it as good, fair, poor, very poor? What about distracted?
How does their memory seem? Intact? Impaired? Is recall different for short-term and longer-term memory? Sensorium: this includes patient’s level and stability of consciousness. Are they disoriented or confused? Do they appear awake, alert, and properly oriented?
Assessing a patient’s insight and judgment over time is also part of cognitive functioning. Is a patient aware of or do they believe they have an illness? I typically document judgment and insight on a scale from very good to good, fair, poor, or very poor. I also describe their fund of knowledge: is it above average, average, below average or very low?
When documenting functioning, I also observe a patient’s posture, gait, and muscle tone. Some people group this with initial appearance and behavior. Does their gait seem steady and normal, or maybe they are unsteady and shuffling? Do they have rigid or hunched posture? What about muscle tone? Does it seem normal? Do you observe muscle atrophy or weakness or possible overdevelopment? These are all things you can document.
Finally, I make sure to ask about sleep patterns and how they’re sleeping. I don’t always see it on many mental status exam templates, but I think it’s important to document, because changes in sleep can indicate changes in mental state. Do they have difficulty getting to sleep or consider it normal? How is the quality of their sleep? Is it interrupted or uninterrupted? Is there a diminished amount of sleep or early morning awakening? What’s the average number of hours they sleep?
A couple of key points to remember for a successful exam: The observation of verbal and nonverbal communication is critical to a patient’s internal state of mind. Take opportunities when they present in an interview to ask for clarification, and respond with respect, empathy, and immediacy. Document general descriptions of the patient, their behaviors, cognitive functioning, feeling and thinking. Note key points in the history that allow you to make a smooth transition later on or to ask about remaining areas of the exam that haven’t come up. Capturing this information at every visit can help monitor course and prognosis. Should a mood disorder be suspected based on components of the mental status examination, additional screening and/or diagnostic tools can be considered.
I hope this has been a helpful primer on conducting a mental status exam in primary care and has given you some tips on identifying and organizing findings, and documenting for future patient encounters.
- American Psychiatric Association. “What is Mental Illness?” August 2018. Accessed August 30,2021. https://www.psychiatry.org/patients-families/what-is-mental-illness
- Kessler R. Lifetime Prevalence and Age-of-Onset Distributions of DSM-IV Disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):593-602.
- Martin DC. The Mental Status Examination. In: Clinical Methods: The History, Physical, and Laboratory Examinations. 1990. Chapter 207. https://www.ncbi.nlm.nih.gov/books/NBK320/#_NBK320_pubdet_
- Foley GN, Gentile JP. Nonverbal communication in psychotherapy. Psychiatry (Edgmont). 2010;7(6):38-44.
- Norris D, Clark M, et al. The Mental Status Examination. Am Fam Physician. 2016. https://www.aafp.org/afp/2016/1015/p635.html
- Folstein MF. Mini-Mental State: a practical method for grading the cognitive state of the patients for the clinician. J Psychiatr Res. 1975;12(3):189-98.
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