Home Health Big Book of Emergency Department Psychiatry
This section should provide a brief description of the patient’s reaction to the clinician’s presence and questions. Examples include being pleasant, cooperative, hostile, guarded, aloof, withdrawn, seductive or flirtatious, and defensive.
Speech can be described using the following descriptors:
The clinician should be aware that there can be a tendency to confuse the topics of mood and affect. We often see in documentation that clinicians incorrectly utilize these interchangeably in the mental status exam.
“Mood” is what the patient answers when you ask them, “How are you feeling?” Examples of mood are “I am fine” or “I have been depressed.” This section also needs to take into consideration the patient’s pattern of emotional stability over a specified time frame. This is what you document in the “history of present illness” section. What you include in the MSE section is how the patient responds to the question of how they are feeling at the time of that interview.
You can also think of this as the patient’s subjective description of their current emotional state.
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