Observation and context #
Record the setting, engagement, arousal and relevant behaviour. Describe what was seen rather than using appearance as a diagnostic shortcut. Consider culture, disability, distress, medication effects and the circumstances of the interview.
Speech, mood and affect #
Describe speech rate, volume, spontaneity and coherence. Distinguish subjective mood from observed affect. Explain affective range, reactivity and relationship to the discussion using examples when useful.
Thought and perception #
Separate the organisation of thought from its content. Explore unusual beliefs and experiences respectfully, including meaning, conviction, distress and functional consequences. Distinguish a reported experience from a phenomenon observed during the consultation.
Cognition, insight and judgement #
Assess arousal and attention before interpreting more demanding cognitive tasks. Describe insight into particular experiences and practical judgement in context. Note what was not tested and any language, education or sensory limitation.
Document uncertainty #
A brief interview cannot establish that every domain is normal. Record unassessed areas explicitly and link significant findings to further clinical assessment. The MSE is a time-specific examination; history and collateral provide the longitudinal picture.
Use in practice
References · 1
- Nitin Sethi, Psychiatric history taking · Supplied PDF pages 21, 22. PDF locators; not a claim of original print pagination.