How to Chart a Mini Mental Status Exam
Document the MMSE as a structured 11-item assessment with a total score out of 30 points, including subscores for each cognitive domain (orientation, registration, attention/calculation, recall, and language/praxis), the patient's education level, and explicit notation that the score is a screening tool requiring clinical correlation—not a standalone diagnosis. 1
Essential Components to Document
Patient Demographics and Context
- Record age, years of education, native language, and cultural background as these factors significantly affect MMSE performance and interpretation 2, 1
- Note any sensory impairments (vision, hearing) that could affect test performance 3
- Document time of day and testing environment, as these can influence results 2
Structured Score Documentation
Chart the MMSE using this format with domain-specific subscores 1, 4:
- Orientation to time (0-5 points): Year, season, date, day, month
- Orientation to place (0-5 points): State, county, town, hospital/building, floor
- Registration (0-3 points): Three unrelated words repeated
- Attention and calculation (0-5 points): Serial 7s or spelling "WORLD" backwards
- Recall (0-3 points): Recall of the three registered words
- Language (0-8 points): Naming (2), repetition (1), three-stage command (3), reading (1), writing (1)
- Praxis (0-1 point): Copy intersecting pentagons
- Total Score: __/30
Critical Interpretation Notes to Include
Document the score interpretation with education-adjusted context 1:
- Score ≥27: Generally normal (but does not rule out MCI)
- Score 24-26: Borderline, requires further evaluation
- Score ≤23: Suggests cognitive impairment (79% associated with dementia)
- For patients with <12 years education, note that lower cutoffs may be appropriate 1
Mandatory Clinical Correlation Statement
Always include a statement that the MMSE score is interpreted within the context of comprehensive clinical evaluation and is not diagnostic by itself 1, 3. Document:
- Whether score is consistent with functional status reported by informant 2
- Any discrepancy between MMSE performance and daily functioning 2
- Specific cognitive domains most affected (e.g., "recall 0/3 suggests memory impairment") 5, 4
Common Charting Pitfalls to Avoid
Do Not Chart MMSE as a Diagnosis
- Never write "MMSE = 22, therefore dementia"—the MMSE is a screening tool requiring comprehensive workup 1, 3
- Always note that abnormal scores warrant further evaluation including neurological exam, functional assessment, informant report, laboratory studies, and imaging 2
Address MMSE Limitations in Documentation
- Note if the patient scored in "normal" range (24-30) but clinical suspicion for MCI persists—document plan for MoCA testing, as MMSE has only 18% sensitivity for MCI 6
- For highly educated patients with borderline scores, note that false-negatives are possible 1
- For patients with limited education, document that false-positives may occur 1
Document Next Steps Based on Score
For abnormal MMSE (≤23), chart the diagnostic plan 2, 3:
- Detailed history from patient and reliable informant
- Functional assessment using standardized tools (FAQ, DAD)
- Informant-based cognitive assessment (AD8, IQCODE)
- Behavioral/mood screening (NPI-Q, PHQ-9)
- Neurological examination
- Laboratory evaluation and neuroimaging
- Consider formal neuropsychological testing
For borderline MMSE (24-26) or normal MMSE with persistent clinical concern, document plan for MoCA administration 2, 6, as MoCA has 90% sensitivity for MCI versus MMSE's 18% 6
Optimal Documentation Template
Use this structure for comprehensive charting 1, 4:
"MMSE administered: 22/30 (Orientation 8/10, Registration 3/3, Attention 3/5, Recall 0/3, Language 7/8, Praxis 1/1). Patient has 10 years education. Score suggests cognitive impairment, most prominent in delayed recall and attention domains. Score is consistent with informant report of progressive memory decline over 18 months affecting IADLs. MMSE is a screening tool and does not establish diagnosis. Plan: Obtain detailed history from spouse, administer functional assessment (FAQ), complete neurological exam, order laboratory workup and brain MRI, refer for formal neuropsychological testing."