What data are recorded regarding patient appearance during a Mental Status Examination (MSE)?

Updated: Sep 24, 2020
  • Author: Jeffrey S Forrest, MD; Chief Editor: David Bienenfeld, MD  more...
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Record the patient's sex, age (apparent or stated), race, and ethnic background. Document the patient's nutritional status by observing the patient's current body weight and appearance. Remember recording the exact time and date of this interview is important, especially since the mental status can change over time such as in delirium.

Recall how the patient first appeared upon entering the office for the interview. Note whether this posture has changed. Note whether the patient appears more relaxed. Record the patient's posture and motor activity. Record the patient's dress and grooming. If nervousness was evident earlier, note whether the patient still seems nervous. Record notes on grooming and hygiene. Most of these documentations on appearance should be a mere transfer from mind to paper because mental notes of the actual observations were made when the patient was first encountered. Record whether the patient has maintained eye contact throughout the interview or if he or she has avoided eye contact as much as possible, scanning the room or staring at the floor or the ceiling.

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