Mental Status Examination (MSE)

• Template structure

  The Mental Status Examination (MSE) template captures these sections automatically from your recording.

  1. Examination Details
  2. Appearance
  3. Behaviour
  4. Speech
  5. Mood and Affect
  6. Thought
  7. Perception
  8. Cognition
  9. Insight and Judgement
  10. Risk
  11. Summary

  Comparing this format to others? See SOAP, DAP, BIRP, and PROC compared.

• Built for

  • Psychiatrist
  • Psychologist
  • Clinical Psychologist
  • Mental Health Nurse
  • General Practitioner
  • Nurse Practitioner
  • Forensic Psychologist
  • Neuropsychologist
  • Social Worker
  • Registered Nurse
  • Clinical Nurse Specialist
  • Geriatrician
  • Neurologist
  • Paediatrician

1. 01 Record or dictate the session

   In-person, telehealth, or hybrid. Audio is deleted immediately once it's processed. If it can't upload, it stays on your own device so you can retry; if it uploads but can't be processed, it's held in Australia for up to 48 hours, then deleted.

2. 02 Pick the Mental Status Examination (MSE) template

   Or make it your default template so future recordings use it automatically.

3. 03 Review and finalise

   Your note is generated in the structure above. Edit anything you want — your practice, your voice — then save to the client record.

• SOAP NoteThe most widely used clinical note format across medicine and allied health. Captures the client's self-report (S), your observations and findings (O), your clinical impression (A), and the next steps (P). Suits problem-focused encounters, follow-ups, and any setting where standardised, transferable documentation matters.
• DAP NoteStreamlined three-part format favoured in mental health, counselling, and psychotherapy. The Data section combines what the client reported with what you observed; Assessment captures clinical impressions and progress against goals; Plan sets next steps and homework. Faster than SOAP without losing clinical reasoning.
• Structured Session Note (BIRP/GIRP/PIRP)Unified structured session note covering BIRP (Behaviour), GIRP (Goals), and PIRP (Problem) formats. The AI selects the appropriate framing based on your documentation preference.
• Process NoteDetailed narrative account of the therapeutic process, including therapist reflections and clinical observations.
• Session NoteGeneral-purpose session documentation suitable for a wide range of clinical and allied health encounters, including therapy sessions and treatment sessions.
• Initial AssessmentComprehensive intake assessment covering presenting concerns, history, risk, and treatment goals.

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