SBIRT Screening Documentation

Documents substance use screening, brief intervention delivered, and referral to treatment for early intervention services.

Consent, Privacy, and Submission Notice

• Submission context
• Consent to document screening and intervention
  Confirm that the individual was informed about the purpose of this documentation and any applicable privacy practices before collecting PII.
• Privacy notice acknowledged
  Acknowledge that only minimum-necessary data should be recorded and shared according to policy and applicable law.
• What happens after I submit
  After submission, the documentation is saved to the audit trail, visible to authorized care team members, and used to support follow-up, referral, or treatment planning.

Client and Encounter Details

• Client or patient identifier
  Use the organization’s internal identifier when possible. Avoid collecting SSN or other unnecessary sensitive identifiers.
• Encounter date
• Encounter location
• Screening tool used

Substance Use Screening Results

• Screening result
• Substance categories identified
• Screening score
  Enter the score only if the selected tool produces a numeric score.
• Screening notes
  Include only clinically relevant observations. Avoid unnecessary PII.

Brief Intervention

• Brief intervention provided
• Intervention method
• Intervention duration (minutes)
• Patient response

Referral to Treatment and Follow-Up

• Referral to treatment needed
• Referral type
• Referral urgency
• Follow-up plan
  Document next steps, responsible party, and any scheduled follow-up contact.

Clinician Attestation

• Clinician name
• Clinician role
• Documentation complete and accurate
  Confirm the record is complete, accurate, and limited to minimum-necessary information.
• Clinician signature