A mental status exam template as Text Blaze snippets, for therapists, psychologists and prescribers who document an MSE at every evaluation. Type a shortcut in your EHR or a document, and the exam appears with a drop-down menu of real descriptors for each domain. The full exam, a psychiatric evaluation, and shorter snippets for the sentences it is built from.

What's inside

Templates:

• /mse, the full exam: appearance, behavior, speech, mood, affect, thought process, thought content, perception, cognition, insight and judgment. Pick from the menus and quote the mood.
• /psycheval, a psychiatric evaluation template for prescribers: chief complaint, HPI, history, MSE, risk assessment, diagnosis, formulation and plan, with the age and follow-up date worked out for you.
• /affect, mood and affect as one sentence: quality, range, intensity, stability and congruence from menus.
• /hpi, the HPI opener: concern, duration, course, onset and impact.

Shorter snippets for commonly typed sentences, complete and ready to edit:

• /exam.wnl, a within-normal-limits exam; /exam.anxious and /exam.depressed for the two most common presentations.
• /cog, /tc and /ij, the cognition, thought-content and insight-and-judgment lines.
• /rb, risks and benefits discussed; /stable, stable on the current regimen.

How it works

1. Install the pack. Type /exam.wnl in your next note and a normal exam appears, ready to edit.
2. Type /mse when a domain differs. Pick from the menus, quote the mood, insert.
3. It lands as text you can still edit, wherever you type.

Edit the language, and set your credentials once and the templates are ready to use. When inserting, use text boxes and drop-down menus to tailor the output to the client and your clinical judgement. Avoid copy and paste notes that raise flags with auditors.