SBIRT Note (Screening, Brief Intervention, and Referral to Treatment)

Date/Time: [Date and time of encounter]

Patient: [Patient name and identifier]

Location/Setting: [Clinic / ED / inpatient / community / other]

Clinician: [Clinician name, credentials, role]

Mode: [in-person / telehealth]

Reason for Screening

[Rationale for SBIRT] (State whether universal/routine screening, triggered by clinical presentation, prior positive screen, quality program requirement, or patient request. If SBIRT was not completed, document reason and plan to reattempt. Keep to 1–3 sentences.)

Screening

(Document each tool administered. For negative screens, keep documentation minimal. For positive screens, include substance use summary.)

• [Tool name]: [self-report / clinician-administered] — Score: [raw score] — [Interpretation/risk category] — [positive / negative / not completed: reason]
• (Repeat for each screening tool administered.)

(If any screen is positive, include substance use summary below.)

Substance use summary: [Substances involved; typical frequency/quantity; last use; high-risk contexts such as mixing substances, injection use, impaired driving, overdose history, or pregnancy]

Assessment

(Include this section when screening is positive or clinically warranted.)

[Synthesis of screening results and clinical context] (Summarize overall risk level: low/moderate/high. Use cautious language such as "screen suggests risky use" or "screen suggests possible substance use disorder"—do not diagnose solely from screening scores. Note relevant co-occurring concerns and any immediate safety concerns or actions taken. Limit to 3–5 sentences.)

Brief Intervention

(Include this section when screening is positive.)

• Counseling approach: [motivational interviewing / FRAMES / 5 A's / other]
• Key topics addressed: [Health risks, recommended limits, safer use strategies, personalized feedback linking use to current health concerns]
• Readiness to change: [Stage of change or importance/confidence rating (0–10)]
• Patient response: [engaged / ambivalent / resistant]
• Agreed-upon plan: [Patient-centered, behaviorally specific goals—e.g., reduction targets, abstinence commitment, harm-reduction steps, follow-up timing]

(If positive screen but brief intervention not performed, state explicitly: "Brief intervention not performed — [reason]. Plan: [follow-up plan].")

Referral / Next Steps

(Include this section when referral is indicated or made.)

• Indication: [high-risk screen / suspected SUD / patient request / safety concerns / other]
• Referral type and destination: [Specialty addiction treatment / medication treatment (MOUD) / behavioral health / peer recovery support] — [specific program or provider]
• Referral method: [resource list provided / appointment scheduled / warm handoff completed / electronic referral sent]
• Patient acceptance: [accepted / declined / undecided] (If declined, document reason and any harm reduction or alternative follow-up offered.)

Follow-Up

• [Planned follow-up interval, setting, and responsible party]
• [Re-screening plan and timeframe, if appropriate]
• [Contingency instructions: crisis resources and return precautions]

Time Documentation

(Include only when billing time-based codes or required by institutional policy.)

• Total SBIRT time: [minutes] [face-to-face / virtual]
• Start/Stop time: [HH:MM] – [HH:MM] (Include if required by payer.)
• (Note: SBIRT time is distinct from separately billed E/M time, if applicable.)

Signature: [Clinician signature, credentials, date/time]

(Omit entire sections when not applicable—e.g., omit Assessment, Brief Intervention, and Referral sections for negative screens. When a clinically expected element is absent, use explicit "Not performed — [reason]" statement rather than silent omission. Do not infer substances, quantities, or diagnoses not directly stated or objectively supported.)