Mental state examination
Use the headings in Bloch et al., 2017, Chapter 6 to organise your notes:
- General appearance and behaviour
- Affect and mood
- Depersonalisation and derealization
- Thought (stream, form, content)
You may use the simple past tense to describe the patient's state at the time of the Standardised Mini-Mental State Examination (MMSE), as in Example 11. This emphasises that the exam findings are specific to the time of conducting the MMSE, but suggests that they are probably subject to change if repeated.
Alternatively, you may use the simple present tense to report the findings of the MMSE. This would contribute toward a consistent reference point for the report by placing the activity of the MMSE at the same time as the interview, the findings of which are forming the basis of this report. It would also grant the MMSE findings more immediate perspective. Over multiple interviews it is important to state at which point the MSE and MMSE were done, especially if the patient's mental state changes or fluctuates.
Both approaches to reporting the findings of the MMSE are acceptable. It is important to be consistent, though, in the approach you adopt.