MSE Domains

Appearance:

Behavior / cooperation:

Speech:

Mood:

Affect:

Thought process:

Thought content (SI / HI / paranoia / AH / VH):

Perception:

Cognition / orientation:

Insight:

Judgment:

Suicidal ideation (current / past / none; plan or intent if present):

Homicidal ideation (current / past / none):

Cognitive screen (MoCA / MMSE / orientation x3 result):

Abnormal Findings

Document examples, onset, severity, impairment, risk link, and plan for follow-up or escalation.

Complete the embedded C-SSRS when suicidal ideation, self-harm, acute risk, or unclear safety status is present; use SAFE-T for full triage when needed.

Focus	Documentation
Status summary	Summarize abnormal findings, baseline comparison, reliability, and limits of exam. Key findings: Baseline comparison: Reliability / limits:
Risk / next steps	Document SI/HI, need for fuller assessment, collateral, follow-up, or referral. SI / HI: Collateral / referral: Follow-up:

Focus

Documentation

Status summary

Summarize abnormal findings, baseline comparison, reliability, and limits of exam.

Key findings:

Baseline comparison:

Reliability / limits:

Risk / next steps

Document SI/HI, need for fuller assessment, collateral, follow-up, or referral.

SI / HI:

Collateral / referral:

Follow-up: