Screen and Interpret

Capture AUDIT-C score, risk threshold context, binge pattern, withdrawal risk, and substances co-used.

Document motivational stage, harm-reduction counseling, referral, medication options, and follow-up.

0/12 Score

How often do you have a drink containing alcohol?

01234

Unanswered

How many standard drinks do you have on a typical drinking day?

01234

Unanswered

How often do you have 6 or more drinks on one occasion?

01234

Unanswered

AUDIT-C positive-screen cue: common non-VA cue is >=4 for men and >=3 for women; follow local policy, including VA/DoD >=5 where applicable.

Tolerance / withdrawal symptoms:

Binge pattern or blackouts:

Patient goal (abstinence / reduction / medication / referral):

Escalate to brief intervention, AUD evaluation, or withdrawal risk plan when indicated.

Plan and Follow-Up

Focus	Documentation
Score / interpretation	Record the result, severity band or screen status, functional impact, and confidence in the response quality. Score / result: Severity / functional impact: Clinical interpretation:
Clinical response	Tie the result to symptoms, risk, differential diagnosis, and treatment response. Response to care: Risk or differential considerations: Plan change:
Next measurement	Set reassessment cadence, patient instructions, escalation criteria, and referral or coordination needs. Reassessment date/interval: Education or referral: Escalation criteria:

Focus

Documentation

Score / interpretation

Record the result, severity band or screen status, functional impact, and confidence in the response quality.

Score / result:

Severity / functional impact:

Clinical interpretation:

Clinical response

Tie the result to symptoms, risk, differential diagnosis, and treatment response.

Response to care:

Risk or differential considerations:

Plan change:

Next measurement

Set reassessment cadence, patient instructions, escalation criteria, and referral or coordination needs.

Reassessment date/interval:

Education or referral:

Escalation criteria: