A mental status exam (MSE) is your own observation of the client, across eleven domains from appearance to judgment. In Confidant you fill it in with clicks, and it goes into the note as your findings.
Turning it on for a client
Not every client needs an exam, so you decide per client. The first time you open a session for a client, the session panel shows a checkbox: Use the exam with followed by the client's name. Tick it and the exam opens. From then on it's offered on every session with that client.
To change it later, open Client settings › Notes and set Mental status exam to On, Off or Not decided. Off hides it, but sessions that already have an exam keep theirs.
Filling it in
After a session is transcribed, the session panel shows a Mental status exam row with Start. It's optional. Do it before you generate the note, and the AI leaves mental status to your exam. You can also add it while the note writes, or after.
Click Start and the exam opens in the panel. Click a domain to see its options.
Pick as many options as apply. Thought process takes one. Insight and judgment take one rating plus any descriptors.
The first option in each domain is the normal finding, shown in green.
All normal fills every empty domain with its normal finding, so you only mark what stood out. It never fills Thought content. "Denies SI/HI" is only ever recorded by you.
Clear empties the exam.
Risk: picking passive SI, active SI or HI adds a reminder to review the risk assessment in the note, and a Risk tag on the exam row.
Every click saves. When you're finished, click Generate note at the bottom, or Done if the note is already writing.
After the note is written
Once the note exists, the exam lives on the session's Measures tab, next to Note, Transcript and Details. It has the same eleven domains, plus All normal and Clear.
In the note, the exam appears as a paragraph labeled Mental Status Exam. Click Edit in Measures beside it to change your picks. The paragraph updates right away, and nothing else in the note is rewritten. You can't type into the paragraph itself. Change the picks instead.
No exam yet? The note shows a Mental status exam row where the paragraph will go. Click Start to add one.
Where it goes in the note
Confidant writes one paragraph from the domains you filled, in order, at the end of the section for observations. Blank domains are left out. The paragraph is included when you copy or export the note.
Format | Section |
SOAP | Objective |
DAP | Data |
BIRP | Behavior |
GIRP | Response |
PIRP | Problem |
SIRP | Situation |
The AI and your exam
The AI never sees your exam. It's only told that you recorded one, so it doesn't write its own or say nothing was observed.
If you add the exam after the note started writing, the AI didn't get that message and may have described mood or affect itself. The note shows a notice above the exam with Regenerate for that section. It rewrites only that section and leaves the rest of the note alone.
Finalized notes
Once a note is finalized, the exam is locked and the Measures tab shows Read-only. To change it, click Unlock… on the note.