CMS SOM App. A, Tag A-1633

a record of mental status;

Interpretive Guidelines §482.61(b)(3)

The purpose of the mental status examination is to obtain evidence of symptoms and signs

of mental disorders, including danger to self and/or others, that are present at the time of

the interview. (Practice Guidelines for the Psychiatric Evaluation of Adults Third Edition

2016, released by the American Psychological Association).

The mental status

examination describes the appearance and behavior, emotional response, verbalization,

thought content, and cognition of the patient as reported by the patient and observed by

the examiner at the time of the examination.

Survey Procedure §482.61(b)(3)

• Review the sample of patient records and verify that the patient’s mental status is

described in the psychiatric evaluation and documented in the medical record.

Ensure the mental status describes such specific examples as the patient’s

appearance and behavior, emotional response to interventions and other

situations, verbalization ability, cognition, etc.

• Interview patients and family members or others significantly involved with the

patient to determine if patient’s mental status is accurately reflected in the record.