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Objective
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Arrival (Select one)
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Clothing (Select one)
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Grooming (Select one)
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Age appearance (Select one)
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Odor 1 (Select one if appropriate)
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Odor 2 (Select one if appropriate)
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Ambulation (Select one)
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Energy (Select one)
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Manner (Select one)
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Participation (Select one)
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Eye contact (Select one)
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Speech (Select one)
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Speech content (Select one)
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Thought process (Select one)
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Describe tics/profanity/etc (example: "When distressed, he repetitively repeated phrases of unclear meaning, such as, "here is not here.")
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Mood (example: "stressed")
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Was affect congruent with mood? (Click if yes)
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Was affect incongruent with mood? (Click if yes)
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Affect (Select one)
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Was patient oriented to person/place/time/situation? (Click if yes)
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Was patient NOT oriented to person/place/time/situation? (Click if yes)
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Describe patient's lack of orientation. (example: " ")
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Was patient NOT psychotic? (Click if yes)
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Was patient psychotic? (Click if yes)
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Hallucinations (Select one if appropriate)
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Describe hallucinations. (example: "hearing a voice instructing him to become violent with others.")
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Delusions (Select one if appropriate)
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Describe delusions. (example: "a belief that she was being watched at all times.")
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Psychosis insight (Select one)
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NO suicidal or homicidal ideation (Click if yes)
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Current OR past suicidal or homicidal ideation (Click if yes)
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Does the patient deny CURRENT SI/HI? (Click if yes)
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Does the patient currently endorse only passive SI? (Click if yes)
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Describe SI/HI thoughts and behaviors. (example: "She shared thoughts such as, "I just don't want to be here anymore.")
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Has patient created a safety plan? (Click if yes)
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Click if no further action was taken (Note: Active SI/HI should be addressed in session and therefore captured in the "Intervention" section)
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Free Text (Instead of using some or all of the above fields, you can write your own MSE section or add information with free text here.)
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