Mental Status Exam Generator

Appearance is observed visually: grooming, hygiene, clothing, and apparent age. It should not become a judgment about attractiveness or style.

• Well groomed: hygiene and dress appear appropriate for the setting.
• Disheveled: clothing/grooming noticeably unkempt.
• Poor hygiene: observable hygiene concerns, not just casual dress.

Behavior is what the client does in session: engagement, cooperation, agitation, withdrawal, psychomotor activity.

Keep this distinct from reported behavior outside session unless it is directly observed or relevant to risk.

Eye contact should be described neutrally. Limited eye contact is not automatically pathological, especially for autistic clients, anxious clients, telehealth, or cultural differences.

Speech describes rate, rhythm, volume, fluency, latency, and interruptibility.

• Rapid: faster than expected but interruptible.
• Pressured: difficult to interrupt; often associated with mania/anxiety/agitation.
• Latent: noticeable delay before responding.
• Monotone: reduced vocal inflection.

Mood is the client’s reported or apparent internal emotional state. Affect is observable emotional expression.

Example: a client may report depressed mood while presenting with restricted or tearful affect.

• Full range: broad, flexible emotional expression.
• Restricted: reduced range but still reactive.
• Blunted: minimal emotional expression.
• Flat: nearly absent emotional expression.
• Labile: rapid/intense shifts in affect.

Congruent means affect matches the stated mood and content. Incongruent means affect does not match, such as smiling while discussing something frightening or tragic.

• Linear: ideas are organized and easy to follow.
• Circumstantial: overinclusive but eventually returns to the point.
• Tangential: moves away from the point and does not return.
• Perseverative: repeatedly returns to the same idea.
• Thought blocking: sudden interruption in train of thought.
• Flight of ideas: rapid shifts with understandable associations.

Thought content is what the thoughts are about, not how they are organized. Delusions, paranoia, obsessions, preoccupations, and rumination belong here.

Perception includes hallucinations, illusions, dissociation-like perceptual changes, and signs of responding to internal stimuli.

For therapy documentation, it is often useful to distinguish “reported” from “observed.”

Insight is the client’s awareness/understanding of symptoms, patterns, needs, and consequences.

Judgment is decision-making capacity in context. It can be fair even when the client has symptoms, and it can be limited even when the client is articulate.