SBIRT Screening, Brief Intervention & Referral Note

Date/Time: [Encounter date and time]

Patient: [Name and ID per system standard (e.g., MRN or DOB)]

Setting: [clinic / ED / inpatient / outpatient] [department if relevant] (If telehealth, append: [audio-video / audio-only])

Provider: [Provider name and credentials]

Indication & Consent

[Indication for SBIRT: routine screening / clinical concern / positive prescreen / follow-up / other] for [alcohol / drugs / both / specific substance(s)]. Patient [consented to screening and intervention / declined / unable to obtain consent]. (If declined or not completed, document reason. Do not leave blank.)

Screening

(Use explicit values or "Declined/Not completed" rather than leaving fields blank.)

• Tool: [AUDIT-C / DAST-10 / ASSIST / CRAFFT / other] administered [self / interviewer] via [paper / tablet / verbal]
• Score: [numeric score]; Risk: [negative / low / moderate / high] (Note threshold basis.)
• Clinical congruence: [aligned with presentation / possible underreporting / conflict with observed signs] (If discrepant, specify briefly.)
• Safety concerns addressed: [overdose history / injection use / withdrawal risk / pregnancy / suicidality / none identified] (If present, note actions taken in 1–2 sentences.)
• Completion: [complete / incomplete] (If incomplete, note missing items and score validity.)

(If screen negative and no counseling beyond routine health education occurred, replace Brief Intervention section with: "Negative screen; no BI indicated.")

Brief Intervention

(Include when screen is positive OR clinical concern exists despite negative screen. Omit entirely if not indicated.)

• Feedback provided: [Patient-centered feedback linking screening result to health risks]
• Patient perspective: [Patient's views and motivation] (Include direct quote for key statements, e.g., goals or ambivalence.)
• Readiness/Confidence: [__/10] / [__/10] (Include if assessed.)
• Goal/Change plan: [abstinence / reduction / safer use / defer decision] — [patient-selected steps]
• Harm reduction: [Specific strategies discussed] (Include if applicable.)

(If BI indicated but declined: document reason if stated and follow-up plan.)

Referral & Plan

(Include when referral is indicated or follow-up actions are planned. Omit if none.)

• Rationale: [Link risk level/functional impact to referral need]
• Service recommended: [outpatient counseling / MAT evaluation / detox / specialty SUD assessment / peer support / other]
• Actions taken: [warm handoff / appointment scheduled / resources provided / ROI obtained]
• Outcome: [accepted / declined] (If declined, note reason and harm-reduction or follow-up plan.)
• Education provided: [Materials/resources given]
• Follow-up: [Timeline and responsible clinician/service]

Time & Attestation

Total SBIRT time (face-to-face): [__ minutes] including [screening / brief intervention / referral activities] (If time not captured, state: "Time not captured—do not bill time-based SBIRT.")

Start/Stop: [HH:MM] – [HH:MM] (Include if required by payer or institutional policy.)

[SBIRT time is separate from other services billed on same date.] (Include if applicable.)

Signature: [Name, credentials, date/time]