Structured psychiatric assessment
General Appearance
Observable, pre-conversation. Capture what you see before the patient speaks.
- Age (apparent vs. stated):
- Grooming / hygiene:
- Dress / attire:
- Distinguishing features:
- Eye contact:
Behavior / Motor Activity
How the patient is moving in the room. Engagement quality with you.
- Psychomotor activity (calm / agitated / retarded):
- Abnormal movements (tics, tremor, stereotypies):
- Cooperation / rapport:
Speech
Production characteristics — separate from thought process.
- Rate:
- Rhythm / prosody:
- Volume:
- Quantity:
- Articulation:
Mood and Affect
Mood is what the patient reports; affect is what you observe.
- Mood (stated, in patient's own words): “”
- Affect — range / intensity / appropriateness / congruence:
Thought Process
The form of thinking, not the content.
- Linearity (linear / circumstantial / tangential):
- Goal-directedness:
- Loosening / flight of ideas / thought blocking:
Thought Content
What the patient is thinking about. Document risk thoughts explicitly.
- Suicidal ideation: Intent / plan / means / protective factors / disposition
- Homicidal ideation:
- Delusions (paranoid / grandiose / somatic / referential):
- Obsessions / preoccupations:
Perception
Sensory and perceptual phenomena across all modalities.
- Auditory hallucinations:
- Visual hallucinations:
- Other (olfactory / tactile / command):
- Dissociative phenomena:
Cognition
Bedside cognitive screen. Note formal testing if performed.
- Alertness / level of consciousness:
- Orientation (person / place / time / situation):
- Attention / concentration:
- Memory (immediate / recent / remote):
- Fund of knowledge:
- Abstract thinking:
Insight and Judgment
Patient's understanding of the illness and capacity to act on it.
- Insight (full / partial / poor):
- Judgment (intact / impaired):
Risk Assessment Summary
A documented rationale — not a single number. Address acute and chronic factors, what is modifiable, and why the disposition is appropriate.
- Acute risk factors:
- Chronic risk factors:
- Protective factors:
- Modifiable factors:
- Overall risk level:
- Plan / disposition rationale:
Clinician signature:
Date / time:
How to use it
Capture the observable items — appearance, behavior, speech, motor activity — in real time, during the visit. Mood and affect, thought process, and perceptual content get filled in as the interview unfolds. Cognition is the bedside screen; insight and judgment are the closing read. Complete the risk block with a rationale, not just a number — what is acute, what is chronic, what is protective, and what is modifiable. Sign it. The MSE is finished before the patient stands up.
Why an MSE template helps
An MSE template does three things that matter on a busy day. It audits safety — if suicidal ideation, homicidal ideation, and hallucinations live in fixed positions, none of them get accidentally skipped on a heavy clinic afternoon. It makes the chart defensible — documentation, not the clinical decision, is what gets clinicians sued. A judge, a peer reviewer, or a payer looking back at the chart wants to see structured risk reasoning, in the same place, every time. And it makes the note easy to drop into the systems you already use: a fixed structure parses cleanly into Epic, athenahealth, Practice Fusion, and the rest, which means the next clinician sees your reasoning the way you wrote it. A template costs nothing and saves the cases that matter.
About this template
This template was assembled by the team at Integrative Psychiatry Manhattan and reviewed by the Sultan Lab for Mental Health Informatics at Columbia University Irving Medical Center and New York State Psychiatric Institute. It is shared freely. There is no signup, no email gate, and no list. Print it, fork it, adapt it to your practice. If it makes one note clearer or one risk assessment more defensible, it has done its job.
Sigmund captures all of this automatically
The version of this work that lives inside Sigmund doesn't ask the clinician to fill the MSE in — he sits in on the visit and drafts it as it unfolds. Speech rate, prosody, psychomotor activity, mood, affect, thought process, and risk content are the things he listens for and watches across the conversation. The risk block arrives with the rationale already drafted from what he heard the patient say in the room. The clinician reviews, edits if needed, and signs. The signature line stays empty until you complete it. See how the evidence engine works and how Sigmund handles psychiatric documentation conventions — including this MSE, progress notes, and risk assessment formats. About the team behind it.
Sigmund is investigational and intended to assist — not replace — clinical judgment. This template is provided as a clinical documentation aid; it does not constitute medical advice and is not a substitute for professional training in psychiatric assessment.
