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The AUDIT-C is a three-item alcohol consumption screen taken from the World Health Organization's ten-item AUDIT, validated as a standalone test by Bush and colleagues in 1998 and scored 0 to 12. Primary care, VA, and behavioral health clinicians use it to find unhealthy drinking and decide who needs a fuller assessment; it never diagnoses. This page covers how to document and interpret AUDIT-C results, with a fictional sample note.
Patient self-report on paper, tablet, or portal, or asked verbally by any clinician or trained staff member; no license, training requirement, or publisher qualification level applies; the treating clinician interprets and documents
Primary care and emergency physicians, nurses, VA and DoD clinicians, perioperative teams, addiction and behavioral health clinicians, quality-measure abstractors, payers and auditors reviewing screening and brief-intervention claims
3 to 6 chart lines (version and standard drink, item pattern and total, threshold applied, patient's account, follow-up, intervention) · administration about 1 to 2 minutes
Brief consumption screen (3 items scored 0 to 4 each, total 0 to 12, past-year window; the first three items of the 10-item WHO AUDIT)
Annual and preventive visits, intake packets, emergency and trauma-center screening, preoperative assessment, VA clinical reminders, behavioral health intakes, and repeated monitoring of drinking during treatment
WHO AUDIT (Saunders and colleagues 1993; manual 2001) with the AUDIT-C validated by Bush and colleagues 1998; WHO copyright with free non-commercial use; named by the USPSTF, NIAAA, VA/DoD, and RACGP for routine screening, mandated by no law; described here for documentation, no items reproduced
The AUDIT-C is the consumption subscale of the Alcohol Use Disorders Identification Test, the ten-item screen the World Health Organization developed through a six-country collaborative project and published in Addiction in 1993 (Saunders, Aasland, Babor, de la Fuente, and Grant); the WHO manual for primary care reached its second edition in November 2001. The full AUDIT covers three domains: the first three items ask about consumption, the next three about dependence-related experiences, and the last four about harms. Bush, Kivlahan, McDonell, Fihn, and Bradley validated the three consumption items as a standalone screen in the Archives of Internal Medicine in 1998, in a sample of male veterans, and the abbreviation AUDIT-C has stuck. At the topic level the three items ask how often the person drinks, how many standard drinks they have on a typical drinking day, and how often they drink heavily on one occasion, each over the past year; each item scores 0 to 4, so the total runs 0 to 12, and a total of zero means no drinking was reported for the year. It can be asked in an interview or completed by the patient on paper, a tablet, or a portal, and NIAAA notes that self-report can be as accurate as direct questioning.
Three facts carry the documentation. First, the score is not self-interpreting: the same three answers represent different amounts of ethanol depending on the standard drink the patient counted (14 g in the United States, 13.45 g in Canada, 10 g in Australia, about 8 g per UK unit) and on the wording of the heavy-occasion item, which the original instrument sets at six drinks for everyone, the US-adapted USAUDIT-C sets lower and by sex, and the VA clinical reminder tailors to sex assigned at birth. Second, the positive threshold is a setting convention rather than part of the instrument: 4 or more for men and 3 or more for women is the US primary-care convention from Bradley and colleagues (2007), the VA calls 5 or more positive for both sexes, Australia's treatment guideline uses 5 or more while the RACGP National Guide uses 4 and 3, and older-adult validations favor 5 for men and 4 for women, so the note has to say which convention it applied. Third, a positive AUDIT-C is a positive consumption screen, not a positive full AUDIT and not a diagnosis; the dependence and harm items, or a DSM-5 criteria assessment in a substance use assessment, come next. The CAGE asks about consequences and dependence rather than consumption, and the DAST-10 is the drug analogue.
The AUDIT-C is the routine adult alcohol screen in US primary care because the USPSTF (2018, grade B) names it with the single-question screen, Medicare pays for an annual alcohol misuse screen, and MIPS measure 431 counts systematic screening with brief counseling, so family physicians, internists, and nurses chart it at wellness and annual visits and in intake packets. The VA has built it into a national clinical reminder with its own sex-tailored wording and threshold, so VA and DoD clinicians document it at nearly every primary care and mental health contact. Emergency departments and verified trauma centers use it or the single question to meet screening and brief-intervention standards; perioperative teams use a high total as the prompt for a withdrawal-risk assessment and a CIWA-Ar monitoring plan; addiction and behavioral health programs record it at the intake beside the substance use assessment and biopsychosocial assessment, and repeat it as a consumption measure during treatment under the conventions of the outcome measure note. Neighbors win in three places: the CAGE when the question is lifetime dependence history, the DAST-10 for drugs other than alcohol, and a pregnancy-specific or adolescent-specific screen where the USPSTF evidence for the adult instruments runs out.
No law, payer, or author prescribes an AUDIT-C note format; what exists is a WHO manual, several national adaptations with different wording and thresholds, and payer and quality rules that ask for a named validated tool, the result, the time spent, and the intervention. What survives review is an entry that names the version and the standard drink, records the three item scores with the total, states the threshold applied, adds the patient's own account of intake, labels the result a screen, names the follow-up it triggered, and documents the intervention with its minutes. Each element below carries the pitfall that most often undermines it.
Version and standard drink. Write which wording was used (original international AUDIT-C, USAUDIT-C, the VA clinical reminder, or a local EHR build) and which standard drink the patient was told to count (US 14 g, Canada 13.45 g, Australia 10 g, UK unit). If the heavy-occasion item was adapted, say so, because a score of 5 on a form that asks about six drinks and a 5 on a form that asks about four drinks for women describe different drinking. Where the EHR carries the version as structured metadata, one phrase in the note still saves the next reader from guessing. Pitfall: "AUDIT-C 5" with no version or drink definition, so nobody can tell a VA reminder result from an original-wording result or what a drink meant.
Mode, language, and completeness. Record whether the patient self-completed it (paper, tablet, portal) or a clinician asked the questions, the language or translation, that all three items were answered, and who computed the total (EHR logic or by hand). Mode affects disclosure, and translated forms may pertain to a version that differs from the original, so a translation is charted with its language and version rather than as plain AUDIT-C. Pitfall: An interviewer-asked score trended against a portal-completed baseline as if the conditions were the same, or a translation charted as plain AUDIT-C.
Item-level pattern, then the total. Chart the three item scores in order with the total (frequency 3, typical quantity 1, heavy occasions 1; total 5 of 12) rather than the total alone. Two patients reach the same total by different routes, steady moderate drinking or intermittent heavy episodes, and the response differs. When every point comes from the frequency item and the quantity and heavy-occasion items score zero, the patient may be drinking within recommended limits, so review actual intake before calling the result a positive; Delaney and colleagues (2014) found score-based results inconsistent with the drinking reported on the same form in 13.8 to 21.1 percent of drinking men and 18.3 to 20.7 percent of drinking women across US and VA samples. Pitfall: "AUDIT-C 4" with no item pattern, or a positive built entirely from the frequency item charted as risky drinking without checking what the patient drinks.
Threshold stated and applied. Name the convention and its source, then apply it: 4 or more for men and 3 or more for women (US primary care, Bradley and colleagues 2007, referenced by NIAAA), 5 or more for both sexes (VA clinical reminder, 2025 guide), 5 or more (Australian treatment guideline), or the higher older-adult cut points. Write the result under that convention, and when a score falls between conventions (a 4 in a man, a 3 or 4 in a woman over 65), say which rule decided it. Pitfall: "Positive" with no threshold, or the US primary-care rule applied inside a VA record or a treatment service that reads 5 or more.
The patient's own account of intake. Add the patient's statement of drinks in a typical week, heavy days, the last drink, and pour size and strength converted to standard drinks (a 750 mL bottle of 12 percent wine is about five US standard drinks; a large pour or a strong craft beer is often two), plus pregnancy, medications that interact with alcohol, and any prior withdrawal. The screen bins intake into categories; the note needs the intake itself, read against the national limits, because that line supports the intervention, the claim, and any later comparison. Pitfall: "Two beers nightly" charted as two standard drinks, or a zero total charted as "no alcohol concerns" in a pregnant patient or someone in early recovery.
Interpretation: a screen, then the follow-up. Write the conclusion as a screening result (positive consumption screen for unhealthy alcohol use; alcohol use disorder not established) and name what happened next: the full AUDIT or a DSM-5 criteria assessment when a disorder is possible, a withdrawal-risk assessment when the total is high and drinking is daily, and the population caveat (older adult, pregnancy, adolescent, translation) when it changes the reading. Higher totals raise the probability of a disorder; no primary authority converts the total into severity bands, and the VA's pairing of score ranges with escalating responses is a care pathway, not a diagnostic scale. Pitfall: "AUDIT-C 8, severe alcohol use disorder" with no criteria assessed, or a positive screen with nothing after it.
Intervention, minutes, rescreen, and record. Document the brief intervention (feedback against the limits, the patient's goal, options offered), the referral made or declined, the face-to-face minutes for any time-based code, the rescreen instrument and date, and where the result lives. Annual screening is the routine convention (Medicare's benefit and MIPS 431 both run on a 12-month cycle); NIAAA advises following up at the next visit after a positive. A primary-care result is a HIPAA record, while the same result created by a federally assisted Part 2 program carries Part 2 consent and redisclosure rules. Pitfall: "Counseled on alcohol" with no content, goal, or minutes, or a bare score claimed under a counseling code.
AUDIT-C DOCUMENTATION BLOCK Date: [ ] Setting: [ ] Clinician: [ ] Encounter: [annual / intake / ED or trauma / preoperative / behavioral health / monitoring] Version: [original wording / USAUDIT-C / VA clinical reminder / local build] Standard drink used: [US 14 g / Canada 13.45 g / Australia 10 g / UK unit] Heavy-occasion item: [as published / adapted by sex; state it] Mode: [self-completed: paper, tablet, portal / asked verbally] Language: [ ] Item scores: frequency [ ] typical quantity [ ] heavy occasions [ ] Total: [ ] of 12 (all points from the frequency item? review intake) Threshold applied: [convention and source] Result: [positive / negative] Prior: [date, same version and drink] [ ] of 12 Change: [which items moved] Patient's account: [drinks per typical week; heavy days; last drink; pour size and strength converted; pregnancy; medications; prior withdrawal] Interpretation: [a consumption screen; disorder not established; pattern: steady use or heavy episodes; population caveat or none] Follow-up triggered: [full AUDIT / DSM-5 criteria assessment / withdrawal risk assessment (CIWA-Ar) / none indicated; result and date] Intervention: [feedback against limits; patient's goal; referral made, declined, or not indicated; face-to-face minutes] Plan: [rescreen instrument and date; treatment or counseling; next visit] Record: [code claimed (bare number); storage location; Part 2 status if created by a Part 2 program; consent on file] Clinician signature / credentials: Date:
Free to use and share, no signup. The PDF includes a one-page cheat sheet with element-by-element pitfalls and a pre-sign checklist; the DOCX is the blank documentation block, ready to adapt. Neither reproduces the questionnaire items.
Scenario: a US internal medicine practice's Medicare annual wellness visit, where a 67-year-old woman's portal-completed AUDIT-C comes back positive under the practice convention, the physician reviews the item pattern and her actual intake, assesses criteria, finds a medication interaction rather than a disorder, delivers timed counseling, and records the claim and the rescreen plan. All details are fictional.
Patient: R.H., 67 · Setting: Internal medicine, Medicare annual wellness visit · Clinician: S. Lindqvist, MD · Note date: 09/16/2026
Screen: AUDIT-C, original three-item wording (heavy-occasion item at six drinks), US standard drink of 14 g shown on the form; self-completed in English on the patient portal on 09/15/2026, all three items answered, total computed by the EHR and confirmed by hand. Item scores in order: frequency 3, typical quantity 1, heavy occasions 1; total 5 of 12. Positive at the practice threshold of 3 or more for women (the US primary-care convention from Bradley and colleagues, 2007, as referenced by NIAAA). Prior: 4 of 12 at the 2025 wellness visit on the same portal form and wording (2, 1, 1); the change is in the frequency item.
Patient's account: In her words: wine with dinner on two or three evenings a week, usually two generous pours from a 7-ounce glass, which we worked out together to about three standard drinks an evening; six or more drinks on a few evenings a year (holidays, a wedding in August); never before evening; last drink two nights ago. About 7 to 9 standard drinks in a typical week, above the NIAAA weekly limit for women and for adults over 65 and at the daily limit on drinking evenings. Takes zolpidem 5 mg most nights and reports two near-falls at night this summer. No prior withdrawal, no prior treatment, no concern voiced by family.
Interpretation: Positive consumption screen for unhealthy alcohol use, with a self-reported pattern above recommended limits; the score is a screen and does not establish alcohol use disorder. Pattern is frequent moderate-quantity drinking rather than heavy episodes (four of five points from the frequency and quantity items). The result would also be positive under the VA convention (5 or more) and the older-adult convention for women (4 or more), so the threshold choice does not change today's reading; it is recorded because it will decide the reading when the score is 3 or 4. The clinical concern is alcohol on zolpidem nights in a patient with near-falls, not the total.
Follow-up assessment: DSM-5 alcohol use disorder criteria reviewed in the visit: R.H. does not meet criteria (no loss of control, craving, tolerance, withdrawal, or role or social consequences). Full AUDIT not administered because the criteria review answered the dependence and harm question. Withdrawal risk low (no morning drinking, no prior withdrawal, no daily drinking); CIWA-Ar not indicated. GGT added to today's labs; fall risk assessment completed as part of the wellness visit.
Brief intervention: Delivered by the physician: feedback on the score and where her weekly intake sits against the limits for women and adults over 65, the alcohol and zolpidem combination as the likely contributor to the near-falls, and a menu of options. R.H. chose a goal of no wine on zolpidem nights and no more than one standard drink on drinking evenings, and accepted a pour-size card. Zolpidem taper discussed and documented in the medication section. Referral not indicated. Face-to-face time: screening review 5 minutes, counseling 16 minutes, documented separately.
Plan and record: Nurse phone check in 4 weeks on the goal and the near-falls; repeat the AUDIT-C on the same portal form at the three-month medication follow-up and at the next wellness visit, interpreted against the same 14 g drink. Annual screening claimed under G0442 and the counseling session under G0443, each supported by the tool, result, content, and time above; MIPS measure 431 met (systematic screen with brief counseling). Result recorded in the general medical record; this practice is not a Part 2 program. R.H. was told the screen is not a diagnosis and agreed with the plan.
This sample is fictional and for educational purposes. It does not describe a real patient or record; the scores, dates, and details are invented to show documentation structure and are not clinical guidance.
Writing these after every session? BastionGPT drafts complete notes from bullets, dictation, or a transcript.
Generate a note from bulletsUnited States: the instrument is a convention; the rules around it are real. No federal or state LAW names the AUDIT-C or prescribes a screening note format. The USPSTF recommendation of 2018 (grade B; CONVENTION, with quality-measure teeth) covers adults 18 and older including pregnant persons, names the AUDIT-C and the single-question screen among the most accurate brief instruments, and finds the evidence insufficient for adolescents; the topic is under update, with a draft statement posted August 5, 2025 that keeps both grades and names the AUDIT-C, the USAUDIT and USAUDIT-C, and the single question, and no final statement had published as of September 2, 2026. NIAAA's clinician resource shows the original wording with the six-drink heavy-occasion item, flags that the US adaptations use lower sex-specific amounts, and directs clinicians to obtain the weekly drinking pattern and assess for alcohol use disorder after a positive screen. The VA/DoD substance use disorder guideline (2021) recommends periodic screening with the AUDIT-C or a single item and a brief intervention for positives; the VA's 2025 quick reference guide states that the clinical reminder tailors the third item to sex assigned at birth, treats 5 or more as positive for both men and women, and requires documentation of brief alcohol counseling, and it pairs rising score ranges with escalating responses as a care pathway rather than as diagnostic bands. Under PAYER POLICY, Medicare's alcohol misuse benefit (NCD 210.8) pays one screen per 12 months under G0442 and up to four counseling sessions a year under G0443, no more than one a day, in a primary care setting; CMS's April 2026 booklet lists emergency departments, inpatient hospitals, ambulatory surgical centers, independent diagnostic testing facilities, skilled nursing facilities, inpatient rehabilitation facilities, and hospices as settings that do not qualify, so a clinically sound emergency-department AUDIT-C is not a Medicare preventive screen. The SBIRT codes (99408 and 99409 for commercial plans, G0396 and G0397 for Medicare, H0049 and H0050 where a state Medicaid program adopts them) are time-based and need a standardized tool, the result, the face-to-face time, and, for the intervention codes, the intervention itself, so a bare score supports none of them; MIPS quality measure 431 (2026) counts a systematic screen at least once in 12 months with brief counseling when unhealthy use is found. Under LAW, 42 CFR Part 2 as amended by the February 2024 final rule (compliance date February 16, 2026, now passed) attaches to records created by a federally assisted Part 2 program, not to the word alcohol: a primary-care AUDIT-C is a HIPAA record, a result recorded at intake in a Part 2 program is a Part 2 record, and the Part 2 consent page covers the mechanics.
Canada and Australia: no requirement, and reference limits the score should be read against. In Canada, no federal or provincial LAW or payer names the AUDIT-C. Canada's Guidance on Alcohol and Health (Canadian Centre on Substance Use and Addiction, January 2023; CONVENTION) sets a continuum of risk: 2 or fewer standard drinks a week is low risk, 3 to 6 moderate, 7 or more increasingly high, with the Canadian standard drink at 13.45 g of ethanol and no known safe amount in pregnancy. A national clinical practice guideline update published in CMAJ in May 2026 (Wood and colleagues) states that existing screening tools have fallen behind that guidance and proposes a simpler approach that asks every patient about consumption and acts on the low-risk threshold, so a Canadian note should say whether an AUDIT-C total or the 2026 approach drove the counseling. In Australia, the RACGP preventive-activities guidance (alcohol recommendation dated June 28, 2024; CONVENTION) names the AUDIT-C for screening adults every two years, and the NHMRC guidelines (December 2020) set the limits at no more than 10 standard drinks a week and 4 on any one day, with a standard drink of 10 g and none under 18, in pregnancy, or while planning a pregnancy. The threshold splits inside the one country: the Guidelines for the Treatment of Alcohol Problems (2021 edition, current online in September 2026) read 5 or more as requiring further assessment, while the RACGP National Guide for Aboriginal and Torres Strait Islander people (4th edition) reads 4 or more in men and 3 or more in women as positive, which is why the convention belongs in the note. No MBS item names the AUDIT-C; screening sits inside attendance and health-assessment items. In every jurisdiction, an AUDIT-C in a pregnant patient is documented with the counseling that no amount is known to be safe rather than against an adult threshold, an adolescent gets an age-appropriate instrument, and a translated form is charted with its language and version, because the WHO manual lists English, Spanish, Hindi, Japanese, and Thai and other translations may not match the original wording.
The AUDIT is copyrighted by the World Health Organization and made available under the non-commercial terms of its 2001 manual and the AUDIT custodial site: the questionnaire may be reproduced and used for any non-commercial purpose without permission, provided it is not materially changed, carries a note that it is a WHO-approved instrument, and no one completing it is charged a fee, and the custodial FAQ states that "as a WHO-approved instrument, the AUDIT is in the public domain" on that basis, while WHO's current permissions policy asks commercial users to seek permission, so this page does not treat that statement as a commercial or EHR-vendor license. The AUDIT-C consumption items were validated as a standalone screen by Bush and colleagues (Archives of Internal Medicine, 1998), and the USAUDIT-C and VA adaptations belong to their agencies. BastionGPT is not affiliated with, or endorsed by, the publisher. This page reproduces no test items, stimuli, norms, or scoring materials.
The numbers behind these errors are specific. In the original validation of 243 male veterans, the three consumption items detected heavy drinking slightly better than the full AUDIT (area under the curve 0.891 against 0.881) and active abuse or dependence slightly worse (0.786 against 0.811), which is the evidence that the AUDIT-C is a consumption screen and not the dependence instrument (Bush and colleagues, 1998). The familiar 4-for-men and 3-for-women convention comes from a later primary-care sample of 392 men and 927 women (sensitivity 0.86 and specificity 0.89 in men, 0.73 and 0.91 in women; Bradley and colleagues, 2007), the VA reads 5 or more as positive for both sexes, and a 2021 community study of 1,577 older adults found the best cut points at 5 or more for men and 4 or more for women (van Gils and colleagues). Delaney and colleagues (2014) found that score-based screening results disagreed with the drinking reported on the same form for 13.8 percent of drinking men and 18.3 percent of drinking women in a US general population sample and 21.1 and 20.7 percent in a VA sample. No published audit counts how often the version, the standard drink, or the threshold is missing from AUDIT-C chart entries; the Medicare, SBIRT, and measure 431 documentation rules described under compliance considerations are what turn those omissions into a claim problem. The BastionGPT Clinical Advisory Board sees the same errors most often in AUDIT-C documentation reviews:
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Each of the three items scores 0 to 4, so the total runs 0 to 12, and a zero means the patient reported no drinking in the past year. The positive threshold is a convention that depends on where you work: 4 or more for men and 3 or more for women is the US primary-care convention (Bradley and colleagues, 2007, referenced by NIAAA); the VA's 2025 guide treats 5 or more as positive for both men and women on its sex-tailored clinical reminder; Australia's treatment guideline reads 5 or more as needing further assessment while the RACGP National Guide uses 4 and 3; and older-adult validations favor 5 for men and 4 for women. None of these is part of the instrument, and none diagnoses anything. Chart the item scores in order, the total, and the convention you applied with its source, so a reader in another system can translate the result. When a score falls between conventions, say which rule decided it.
Use the convention your setting has adopted and write it down. In general US primary care that is 3 or more for women and 4 or more for men, from a validation in which sensitivity for women was 0.73 at that cut point, so a negative in a woman rules out less than a negative in a man. In the VA the clinical reminder decides: 5 or more is positive for both sexes, and the third item is already tailored to sex assigned at birth. For adults over 65, a 2021 community validation found the best cut points at 5 or more for men and 4 or more for women, and Australian older-person guidance discusses a lower cut point of 4 with at least annual review; document which you applied rather than silently changing the number because of age. In pregnancy, the USPSTF includes pregnant adults in the screening recommendation, but the counseling question is any use, not a threshold, so chart the counseling that no amount is known to be safe. For adolescents the USPSTF finds the evidence insufficient, and NIAAA and the AAP point to youth-specific instruments, so do not lower the adult cut point for a teenager.
The full AUDIT has ten items in three domains: three about consumption, three about dependence-related experiences, and four about harms. The AUDIT-C is the first three alone. In the original validation the three items detected heavy drinking slightly better than the full instrument and active abuse or dependence slightly worse (Bush and colleagues, 1998), which is exactly the division of labor: use the AUDIT-C to find unhealthy drinking quickly, and use the full AUDIT, or a DSM-5 criteria assessment, when a positive screen needs the dependence and harm picture before any severity language enters the chart. Australia's treatment guideline reads a full AUDIT total of 8 or more as presumptive hazardous or harmful drinking and 15 or more as a prompt to assess for dependence; those are conventions for the ten-item instrument and do not transfer to the three-item total. Document "AUDIT-C positive" and "full AUDIT" as separate results with their own dates, and record the criteria assessment in the substance use assessment rather than in the screen line.
No. It is a positive consumption screen, which raises the probability of unhealthy alcohol use and of a disorder but establishes neither; alcohol use disorder and its severity come from DSM-5 criteria, not from the total. The defensible chain in the chart is: the screen result under a named convention; the patient's actual intake; a criteria assessment or the full AUDIT when a disorder is possible; a withdrawal-risk assessment (and a CIWA-Ar plan where indicated) when the total is high and drinking is daily; then the diagnosis, if any, in its own line. Write "positive screen; alcohol use disorder not established" until the criteria are assessed, and never map the total onto severity bands: no primary authority publishes them, the VA's pairing of score ranges with escalating responses is a care pathway, and in specialty treatment populations heavy consumption is so common that the three items cannot grade disorder severity.
Because the items count drinks, and a drink is 14 g of ethanol in the United States, 13.45 g in Canada, 10 g in Australia, and about 8 g per UK unit. The same answer of three drinks a night is about 42 g in a US chart and 30 g on an Australian form, and a 750 mL bottle of 12 percent wine is about five US standard drinks, seven Australian ones, and nine UK units, so a score with no drink definition is not comparable across borders or between EHR builds. Convert by volume and strength rather than counting containers: a 7-ounce pour of wine is well over one US drink, a 16-ounce can of 8 percent beer is about two, and patients routinely under-count both. Chart the standard drink the patient was told to use, put the converted weekly total in the patient's account, and keep the definition constant when you trend the score.
Not on the score alone. The AUDIT-C is an accepted standardized tool, so it can support the screening component, but every code is PAYER POLICY with its own conditions. Medicare pays one alcohol misuse screen per 12 months under G0442 and up to four counseling sessions a year under G0443 for beneficiaries who screen positive, no more than one a day, in a primary care setting; the April 2026 CMS booklet excludes emergency departments, inpatient hospitals, ambulatory surgical centers, skilled nursing facilities, inpatient rehabilitation facilities, and hospices, so an emergency-department screen is clinically right and still not a Medicare preventive service. The SBIRT codes (99408 and 99409 commercially, G0396 and G0397 for Medicare, H0049 and H0050 where a state Medicaid program adopts them) are time-based and need the named tool, the result, the face-to-face minutes, and, for the intervention codes, a documented intervention with content; a bare score meets none of that, and Medicaid rules are state-specific. MIPS measure 431 (2026) is a quality measure rather than a payment code: it counts a systematic screen within 12 months and brief counseling when unhealthy use is found. The sample above shows the minimum: tool, result, criteria review, counseling content and goal, and separate minutes.
For routine prevention, annual screening is the working convention: Medicare's benefit and MIPS measure 431 run on a 12-month cycle, the WHO manual favored annual screening, and Australian guidance for older people asks for at least annual review; the USPSTF sets no interval. Repeat sooner when the result will monitor an intervention, after a positive, or when circumstances change (pregnancy, a new interacting medication, an injury, liver disease, preoperative planning). Trending is legitimate as a consumption measure, with one rule: keep the version, the heavy-occasion wording, the standard drink, the mode, and the scoring logic the same on both occasions and chart the item pattern each time, so a fall from 7 to 4 can be read as fewer heavy episodes rather than as a changed form. No validated change score defines treatment response, so describe the change; do not label it. Serial results follow the conventions of the outcome measure note.
At the topic level the items ask how often the person drinks, how many standard drinks they have on a typical drinking day, and how often they drink heavily on one occasion, each over the past year. This page does not print or paraphrase the questions or response options; the WHO manual (2001) and the AUDIT custodial site are the sources of record. The rights position is more precise than the phrase public domain suggests: no permission is needed for any non-commercial use, the questionnaire may be reproduced on printed forms and in a health system's own records for administration, it must not be materially changed, it should carry a note that it is a WHO-approved instrument, and no one completing it may be charged a fee. On that basis the custodial FAQ calls the instrument public domain, but WHO's current permissions policy asks commercial users to seek permission, so an EHR vendor, an ad-supported web tool, or a paid app should clear rights rather than rely on that phrase. If you use a national adaptation, name it (USAUDIT-C, VA clinical reminder) and cite its agency as well as Saunders 1993 and Bush 1998.
Yes. Give it the facts (the wording and drink definition used, mode and language, the three item scores, the threshold your setting applies, the patient's intake in their words, any criteria or withdrawal assessment and its result, the intervention and its minutes, and where the result is stored) and it drafts the full entry: the screen result with the convention named, the item pattern, the patient's account converted to standard drinks, a screening-level interpretation, the follow-up, the intervention, the plan, and the record placement, ready for your review. It can also check a finished note for a missing version or drink definition, a total with no item pattern, a positive with no threshold, a severity band charted as a diagnosis, containers counted as drinks, or an intervention with no content or minutes. BastionGPT is HIPAA-compliant with a signed BAA on every plan, and your data is never used to train models.
The instrument facts and compliance claims on this page trace to these sources, last verified September 2026:
Educational content, not legal or billing advice. Sample notes are fictional. Follow your organization's policies and your board, payer, and jurisdiction requirements.