Documentation for Clinicians: Mental Status Exams
Documentation! Such an important topic. I want to talk to you about mental status exams (MSE), but first: I recently came across a useful article regarding documentation, and want to pass it along. It’s entitled, Effective Documentation: How to Keep Your Head Above Water… Here are a few excerpts I found especially helpful:
Clinical Documentation is an inevitable tedious task that everyone in the mental health world must become familiarized with doing well! It is an essential part of the clinical process, and serves somewhat as a partner and road map for the clinician. It cements the clinical process in history, and guides the evolution of the clinical process from intake to termination.
. . .Personally, I believe documentation is a creative art form that conveys a story that when completed appropriately, can be deciphered easily by both the novice and seasoned clinician as well as across multidisciplinary personnel. Yes, respect is attached to the quality of one’s clinical documentation. . .
.My definition of quality documentation is one in which the both the professional and the laymen should be able to understand and vividly follow the transition of the clinical process for either professional input and guidance and/or learning. It should covey the same understanding across all professions although each profession would naturally view through their own professional schemas for it to be practical for them.
Now, back to the mental status exam! Tomorrow night in my First Monday supervision group, we are covering MSEs (I shared this brief article in preparation). I’ve asked everyone to bring along an example of one they’ve recently completed, so we can -quite literally- compare notes. The mental status exam is simply a portion of your note-taking where you describe what you are observing in your client as objectively as possible. Categories generally cover appearance, behavior, cognitions and thinking, emotions. I also find it valuable to add a person’s strengths, or idiosyncracies that are useful to know in order to provide better person-centered care.
Historically clients have been reduced to descriptions of symptoms or a focus on their problems, but that’s really not useful, or accurate. I think what’s most important is describing the person as they are: a whole, nuanced being with strengths and weaknesses who is trying their best. Capture their complexity and beauty! Describe them as respectfully as possible; think how you would want to be described, were you to find yourself in their set of circumstances. Let all your documentation be a sincere effort to promote and contribute to the growth and healing of your client.
Do you have questions on MSEs? Find them useful, confusing, helpful or otherwise?