Mental Status

Equipment Needed

• Mini-Mental State Exam or similar tool (optional)

What to Say to the Patient

• "I'm going to ask a few questions to check your memory, attention, and thinking."

Inspection Steps

• Appearance, behavior, mood/affect
• Speech (rate, tone, fluency)
• Thought process/content

Normal Findings

• Alert and oriented x4
• Appropriate mood/affect
• Intact memory/recall
• Coherent thought process

Abnormal Findings

• Disorientation
• Flat/labile affect
• Impaired recall/concentration
• Disorganized thought process
• Suicidal/homicidal ideation

Common Mistakes

• Not formally assessing orientation (person/place/time/situation)
• Assuming normal cognition without testing recall

Documentation Example

Alert and oriented x4. Mood euthymic, affect appropriate. Thought process linear and goal-directed. Recall 3/3 at 5 minutes.