A CAGE screening note only does its job if the result is easy to act on later. That means recording which items were endorsed, the resulting score, what that score means for risk, and, when the screen is positive, the specific next step it triggered. This page is a template for that documentation, not a diagnostic tool: a positive screen is a reason to assess further, not a conclusion on its own.
What Every CAGE Documentation Note Needs
| Section | What it captures |
|---|---|
| Screening context | Why the screening was given today, and the setting: primary care, intake, or emergency visit |
| Responses summary | Each of the four items and whether it was endorsed, in the patient's own words when useful |
| Score and interpretation | Total items endorsed, out of four, and what that score means for risk |
| Follow-up and referral | What happens next on a positive screen: brief intervention, referral, or further assessment |
| Recommendations linkage | Every next step tied to the specific result, so nothing reads as generic advice |
Download blank template (PDF)Free, no signup required.
Example of a Completed Screening Summary
Illustrative only: this is a hypothetical result for a fictional patient, not output from a real screening, and contains no protected health information.
- Responses: 2 of 4 items endorsed. Endorsed "Cut down" and "Guilty"; did not endorse "Annoyed" or "Eye-opener."
- Score: 2. Suggestive of at-risk drinking; warrants further assessment rather than a standalone diagnosis.
- Follow-up. Discussed the result with the patient, provided brief intervention on reducing intake, and scheduled a follow-up visit in two weeks to reassess.
How ClinicFrame Writes This Section
ClinicFrame is an ambient AI scribe built around custom note templates: you define the sections a CAGE documentation note needs, describe what belongs in each one, and generate a draft from your own summary of the encounter. You review and edit every entry before it becomes part of the record.
