An example of a validated questionnaire for alcohol screening is the 10 item Alcohol Use Disorder Identification Tests (AUDIT). The first three questions of the AUDIT, the AUDIT-C, ask about alcohol consumption, and can be used reliably and validly to identify unhealthy alcohol use. The four-item CAGE questionnaire is generally inappropriate for screening general populations, as it aims to identify only severely alcohol dependent patients.

• The alcohol use status screening must have occurred within the first day of admission (by end of Day 1). This includes the day of admission which is defined as Day 0 and the day after admission which is defined as Day 1.
  EXCEPTION:
  If the screening was performed within 3 days prior to admission, i.e., at the transferring facility, in another inpatient hospital unit, emergency department or observation unit, the screening documentation must be present in the current medical record.
• If patient has a blood alcohol test with a result of .08 g/dL or greater or the clinician documents the patient was acutely intoxicated per blood alcohol test results, select Value “2.”
  • The 0.08 limit is a blood alcohol concentration (BAC) reported in g/dL. If results are given in mg/dL, convert to g/dL by moving the decimal point 3 places to the left.
    Examples:
    • A 100 mg/dL serum ethanol level is equivalent to a 0.10 g/dL BAC.
    • An 80 mg/dL serum ethanol level is equivalent to a 0.08 g/dL BAC.
• Screening may be done with a “validated” Single Alcohol Screening Question (SASQ) in order to identify those patients with no risk or low risk or who do not drink. Further screening should be done with a validated tool for those patients with a positive result to determine if there is need for a brief intervention.
  Examples of SASQs include:
  • “On any single occasion during the past 3 months, have you had more than 5 drinks containing alcohol?” (“Yes” response is considered positive.)
  • "When was the last time you had more than X drinks in 1 day?" (X = 4 for women and 5 for men) (Within the last 3 months is considered positive.)
  • “How many times in the past year have you had X or more drinks in a day?" (X = 5 men and 4 women) (Response of >1 is considered positive.)
  • How often have you had 6 or more drinks on one occasion in the past year? (Ever in the past year considered positive.)
  • How often do you have X or more drinks on one occasion? (X = 4 for women and 5 for men) (Ever in the past year considered positive.)
• Refer to the Inclusion Guidelines for examples of commonly used validated screening tools; note that the CAGE, although a validated tool, is not recommended for this measure set.
• If there is documentation in the medical record indicating the patient drinks alcohol and conflicting documentation indicating the patient does not drink alcohol, select Value “6” since alcohol use status is unable to be determined.
  EXCEPTION:
  If there is documentation of a validated questionnaire for alcohol screening completed within the first day of admission, select the appropriate Value 1 or 2 regardless of conflicting documentation.
• When there is conflicting information in the record with regard to risk, for instance, the results from a validated screening tool are documented as both low AND moderate/high risk, select Value “2” indicating the highest risk.
• Cognition refers to mental activities associated with thinking, learning, and memory. Cognitive impairment for the purposes of this measure set is related to documentation that the patient cannot be screened for alcohol use due to the impairment (e.g., comatose, obtunded, confused, memory loss) within the first day of admission (by end of Day 1).
• If there is documentation within the first day of admission (by end of Day 1) that the patient was psychotic, symptoms of psychosis, e.g., hallucinating, non-communicative, catatonic, etc., must also be documented for the patient to be considered cognitively impaired.
• If there is documentation to “rule out” a condition/diagnosis related to cognitive impairment, Value “7” cannot be selected unless there is documentation of symptoms.
  Examples:
  • Patient actively hallucinating, rule out psychosis. (Select Value “7”).
  • Rule out psychosis. (Cannot select Value “7”).
• If there is documentation within the first day of admission (by end of Day 1) of any of the examples below, select Value “7” regardless of conflicting documentation.
  Examples of cognitive impairment include:
  • Altered Level of Consciousness (LOC)
  • Altered Mental Status
  • Cognitive impairment
  • Cognitively impaired
  • Cognitive impairment due to acute substance use, overdose, acute intoxication
  • Confused
  • Dementia
  • Intubation and patient is intubated through the end of Day 1
  • Memory loss
  • Mentally handicapped
  • Obtunded
  • Psychotic/psychosis with documented symptoms
  • Sedation
• Documentation of cognitive impairment overrides documentation of an alcohol use screen and therefore would not be considered "conflicting documentation." Even if the family or others tell staff the patient uses alcohol, the patient could not be appropriately screened and subsequently counseled due to cognitive impairment. Select Value “7.”

• Consultation notes
• Emergency department record
• History and physical
• Nursing admission assessment
• Nursing Admission Notes
• Physician Progress Notes