The mental state exam begins the moment the health professional meets the subject. The interviewer should make note of the person’s appearance (such as signs of malnutrition, lack of cleanliness), changes in motor activity during the interview, use of language, presence of eye contact, and the ability to relate to the interviewer.
Brief mental state assessment
_ Appearance - self, clothing, marks
_ Behaviour on observation (e.g. does s/he look perplexed)
_ Look and smell for signs of alcohol, drugs, disease
_ Assess speech - form, content, flow
_ Mood, subjective as the patient defines, objective (affect) as the clinician observes
_ Thought processes (delusions, obsessions, ideas of helplessness, morbid ruminations, etc)
_ Perception, illusions and hallucinations (auditory, visual, olfactory and somatic)
_ Cognitive function (i.e., orientation, time, place, person, short-term and long-term memory)
_ Insight (how aware the patient is of his or her psychological problems)
The presence of police officers, soldiers, prison officers or other law enforcement officials in the examination room for whatever reason should be noted in the clinicians official medico-legal report. their presence may be grounds for disregarding a medico-legal report. Copies of all medico-legal reports should be retained by the examining clinician. Under no circumstances should a copy of the medico-legal report be transferred to law enforcement officials. At the time of detention, a thorough medical examination should be conducted. access to a lawyer should be provided at the time of clinical evaluation.
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