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Documentation Index

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Audience: Licensed clinicians, clinical supervisors, and case managers documenting in the patient chart. Spec: CL-31 — Co-Occurring Disorder Integrated Documentation Compliance: AHCCCS AMPM Policy 320-O, CARF Behavioral Health Standards §§4.A–4.C, 42 CFR Part 2. Last Updated: 2026-05-12

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1. What COD documentation does

CL-31 lets you document an integrated assessment, treatment plan, and progress notes for clients with both a mental-health (MH) and a substance-use (SUD) diagnosis (“co-occurring disorder”). It adds three things on top of the standard chart:
  • A COD assessment tab with ASI-6, BASIS-32, and GAIN-SS instruments.
  • A COD treatment plan extension with ASAM level of care and dimensions 5/6 notes.
  • A dual-diagnosis progress note section that records SUD content under 42 CFR Part 2 consent.

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2. Marking a chart as COD

The COD indicator unlocks the integrated treatment plan and dual-diagnosis progress note. You can set it two ways:
  1. Automatic prompt — After you save your first COD assessment for a chart, the platform asks “Set COD Indicator?”. Click Set COD Indicator to mark the chart.
  2. Manual toggle — Use the COD badge near the patient name in the chart header at any time.
The badge displays “COD” as a muted tag once set. Removing the indicator does not delete COD assessments — it only hides the integrated plan/progress-note sections.

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3. Creating an ASI-6 assessment

  1. Open the patient’s chart and select the COD Assessments tab.
  2. Click New Assessment. The assessment dialog opens.
  3. Choose ASI-6 as the instrument type at the top.
  4. Expand each of the seven domains (Medical, Employment, Alcohol, Drug, Legal, Family/Social, Psychiatric) and enter a composite score 0–9. The severity badge is computed automatically (0–1 None, 2–3 Low, 4–5 Moderate, 6–9 Severe).
  5. Add interviewer notes per domain. Notes are optional for Save Draft and required for Complete Assessment.
  6. Click Save Draft to keep working, or Complete Assessment to finalize.
  7. The dialog header shows “X of 7 domains scored” so you can track progress.
About SUD domains (Alcohol, Drug): You can always enter assessment scores. Read access for other users is gated by 42 CFR Part 2 consent — see §7.

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4. BASIS-32 and GAIN-SS (Phase 2 generic form)

The Phase 2 release captures BASIS-32 and GAIN-SS as a single total-score plus summary notes. The full subscale UI ships in the Phase 3 release. The instrument header shows: “Full subscale breakdown coming in a future release.”

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5. Amending a complete assessment

On any assessment with status Complete, click Amend in the row’s actions. The form reopens. Save your changes; the status moves to Amended and the original is preserved in the audit log.

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6. COD treatment plan extension

When a chart has the COD indicator set, the standard CL-03 treatment plan adds a collapsible Co-Occurring Disorder (COD) Level of Care section between the Goals section and the signatures.
  • ASAM level — Pick from 0.5 through 4.0. Leave blank for “Not yet determined.”
  • Dimension 5 / Dimension 6 notes — Optional free-text fields for relapse potential and recovery environment.
  • Goal tagging — Each treatment goal gets a Domain chip: MH, SUD, or Both. Defaults to Both when COD is set. Keep goal descriptions general; document SUD-specific details in the progress note SUD section.
  • MOUD link — When CL-21 (MOUD) is enabled and a MOUD episode is linked, a read-only callout shows medication, current phase, and start date.

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7. Writing a dual-diagnosis progress note

  1. Create a progress note as usual (CL-04). When the chart’s COD indicator is set, a COD Session Type selector appears with options Standard (MH only) and Dual Diagnosis (COD).
  2. Pick Dual Diagnosis (COD) and save the note.
  3. Re-open the saved note. If the patient has an active 42 CFR Part 2 consent on file, the SUD section renders four fields:
    • SUD symptom summary
    • Substance use since last session
    • Cravings and urges
    • Treatment response
  4. If consent is missing, the SUD section is replaced with an amber banner: “SUD documentation requires 42 CFR Part 2 consent.” Click Manage Consent → to open the CL-11 consent workflow.
  5. The consent check runs on every form load — you cannot bypass it.
Consent is captured in CL-11. Open the Consent section of the chart, add a sud_counseling_notes consent for the disclosure recipient, and have the patient sign. Once active, the SUD section unlocks for any clinician with cl.cod_progress_notes.view_sud.

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9. FAQs

Why can I enter SUD scores but not always read them later? Entering data is gated by your role permissions; reading SUD content (notes, redisclosure exports) is gated by patient consent under 42 CFR Part 2. Default-deny applies on any consent-check failure. Can I edit the auto-derived severity badge? No. Severity is a deterministic function of the composite score in Phase 2. The COD prompt did not appear after my first assessment. The prompt fires once per browser session per chart. If you dismissed it, set the COD indicator manually from the chart header. Where do I see all my COD patients? The COD Caseload view ships in Phase 3 (see CL-31 spec §US-5).