SBIRT Screening Documentation

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

Consent, Privacy, and Submission Notice

• What happens after I submit?
• Consent to document screening and intervention
• Privacy and information-sharing disclosure acknowledged

Encounter Details

• Encounter date
• Encounter time
• Service setting
• Reason for screening
• Screening tool used

Screening Results

• Substances screened
• Overall screening result
• Alcohol screening score
• Drug screening score
• Screening notes
  Document only clinically relevant observations. Avoid unnecessary PII.

Brief Intervention

• Brief intervention delivered
• Intervention type
• Readiness to change
• Brief intervention summary

Referral to Treatment

• Referral needed
• Referral type
• Referral destination
  Enter the program, clinic, or service name only. Avoid unnecessary identifiers.
• Referral contact method
• Follow-up date

Disposition and Follow-Up

• Disposition
• Follow-up plan
• Additional comments
  Document only information necessary for care coordination and the audit trail.