Mental Status Exam (MSE)

The Mental Status Exam, or MSE, is a document that’s often included in other clinical documents as a tab, but the standalone form is also available.

1. You must first have the client open, click the Search icon.
2. Type Mental Status Exam into the search bar.
3. Click to select Mental Status Exam (Client).
4. In the CDAG Program Enrollment window pop-up, click the drop down and click to select the appropriate program.
5. Click OK to continue.
   
6. The Mental Status Exam document will open. Complete the document. If a previous MSE was completed, it will pull forward the most recent information. Otherwise, all sections will default to “Not Assessed.”
   1. If you did not assess that section, select “Not Assessed.” This will lock your ability to check any of the boxes.
   2. If you find that the person is within normal limits (WNL) for a section, you can simply check the “WNL” radio button at the top of the section. This will lock your ability to check any of the boxes, as this designation covers the requirements.
   3. Helpful Tip: If the person is within normal limits for all sections, you can select “All Within Normal Limits (WNL)”
   4. If you assessed a section, select all options that apply. If you select “Other”, make sure to complete the text field.
      
   5. Some sections, such as Suicide/Homicide, are single select and must be completed. However, if clicking “None” then the options will mark all as “No” or grey out, depending on the section.
   6. Some sections, including the Suicide/Homicide section, also have a Comments section for you to add more detail.
   7. Some sections, such as orientation, request evidence of the clinician’s determination.
      
7. Once completed, click Sign to complete and generate the document.
   1. There is a section at the very end for additional comments. You can also use this box to summarize the MSE results.
   2. There is also a Review section. This is for MSEs that are completed frequently. This allows you review the most recent MSE and make minor changes without having to re-enter all the sections. You can select N/A if you started over.
   3. You can use “Not Clinically Indicated” when you’re completing frequent MSEs and a section does not need to be completed every time.