Registered Nurses´ Association of Ontario
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Outline of a Mental Health Status Assessment
The following elements may be included in a mental status assessment:
APPEARANCE:
- Age: (chronological age and whether person looks this age)
- Sex, Race
- Body build (thin, obese, athletic, medium)
- Position (lying, sitting, standing, kneeling)
- Posture (rigid, slumped, slouched, comfortable, threatening)
- Eye contact (eyes closed, good contact, avoids contact, stares)
- Dress (what individual is wearing, cleanliness, condition of clothes, neatness, appropriateness of garments)
- Grooming (malodorous, unkempt, dirty, unshaven, overly meticulous, hairstyle, disheveled, makeup)
- Manner (cooperative, guarded, pleasant, suspicious, glib, angry, seductive, ingratiating, evasive, friendly, hostile)
- Attentiveness to examiner (disinterested, bored, internally preoccupied, distractible, attentive)
- Distinguishing features (scars, tattoos, bandages, bloodstains, missing teeth, tobacco- stained fingers)
- Prominent physical irregularity (missing limb, jaundice, profuse sweating, goiter,wheezing, coughing)
- Emotional facial expression (crying, calm, perplexed, stressed, tense, screaming, tremulous, furrowed brow)
- Alertness
MOTOR:
- Retardation (slowed movements)
- Agitation (unable to sit still, wringing hands, rocking, picking at skin or clothing, pacing, excessive movement, compulsive)
- Unusual movements (tremor, lip smacking, tongue thrust, mannerisms, grimaces, tics)
- Gait (shuffling, broad-based, limping, stumbling, hesitation)
- Catatonia (stupor, excitement)
SPEECH:
- Rate (slowed, long pauses before answering questions, hesitant, rapid, pressured)
- Rhythm (monotonous, stuttering)
- Volume (loud, soft, whispered)
- Amount (monosyllabic, hyper-talkative, mute)
- Articulation (clear, mumbled, slurred)
- Spontaneity
AFFECT:
- Stability (stable, fixed, labile)
- Range (constricted, full)
- Appropriateness (to content of speech & circumstance)
- Intensity (flat, blunted, exaggerated)
- Affect (depressed, sad, happy, euphoric, irritable, anxious, neutral, fearful, angry, pleasant)
- Mood (reported by patient/client)
THOUGHT PROCESS:
- Coherence (coherent, incoherent)
- Logic (logical, illogical)
- Stream (goal-directed, circumstantial, tangential {diverges suddenly from a train of thought}, loose, flight of ideas, rambling, word salad)
- Perseveration (pathological repetition of a sentence or word)
- Neologism (use of new expressions, phrases, words)
- Blocking (sudden cessation of flow of thinking & speech related to strong emotions)
- Attention (distractibility, concentration)
THOUGHT CONTENT:
- Suicidal or homicidal ideations
- Depressive cognition (guilt, worthlessness, hopelessness)
- Obsessions (persistent, unwanted, recurring thought)
- Ruminations
- Phobias (strong, persistent, fear of object or situation)
- Ideas of reference Paranoid ideation
- Magical ideation
- Delusions (false belief kept despite no supportive evidence)
- Overvalued ideas
- Other major themes discussed by patient/client
PERCEPTION:
- Hallucinations (auditory, visual, olfactory [smelling], gustatory [taste], tactile)
- Illusions (misinterpretation of actual external stimuli)
- Depersonalization
- Déjà vu, Jamais vu
INTELLECT:
- Global evaluation (average, above or below average)
INSIGHT:
- Awareness of illness
Adapted from: American Psychiatric Association (1994). Diagnostic & Statistical Manual of Mental Disorders. 4th Edition. American Psychiatric Association,Washington D.C.; Trzepacz, P.T. & Baker. R.W. (1993). The Psychiatric Mental Status Examination. Oxford University Press; Robinson, D.J. (2000). The Mental Status Exam Explained. Rapid Psychler Press.
