IOP DOCUMENTATION TIMELINE CHECKLIST

Client Initials: __________
Counselor: __________
Intake Day: __________
*Highlight = completed by counselor
Admit Day: __________

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FIRST 24 HOURS
□ Initial Service Plan (must be completed by an Alcohol and Drug Counselor)
□ Mental Health Diagnostic Assessment referral
□ Vulnerable Adult Determination
 □ Individual Abuse Prevention Plan (if applicable)
□ Provide educational material for Opioid Use Disorder
□ DAANES (admin staff)
□ Intake Packet (admin staff)
□ MH Intake Form (admin staff)
□ ROI signed for support person(s) (admin staff)
□ ROI signed for professional involvement

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WITHIN FIVE DAYS
(If client admits on Thursday, Comprehensive Assessment must be completed by Tuesday.)
□ Comprehensive Assessment
□ Comprehensive Assessment Summary/Update (if original is >30 days old)
□ Assessor signature (same day as document creation)
□ Call support persons for collateral / invite to family group (optional)
□ Call legal contacts to notify client is in treatment (optional)

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WITHIN 30 DAYS
□ Individual Treatment Plan (client signature or note verbal agreement)

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WITHIN TEN DAYS
□ Mental Health Diagnostic Assessment (MH provider)

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DUE EVERY 30 DAYS
(due every 30 days or when a clinical change/significant event occurs)
□ Treatment Plan Review – First Progress Review
□ Treatment Plan Review – Second Progress Review
□ Treatment Plan Review – Third Progress Review
□ Treatment Plan Review – Fourth Progress Review
□ Treatment Plan Review – Fifth Progress Review
□ Treatment Plan Review – Sixth Progress Review

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DAILY GROUP NOTES
□ Monday
□ Tuesday
□ Wednesday
□ Thursday

□ Friday

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WEEKLY INDIVIDUAL NOTE
(cover the 6 ASAM Dimensions in DAP, SOAP, or Progress Note)
□ Weekly Individual Session Note

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WEEKLY TREATMENT SERVICE NOTES
□ Week 1
□ Week 2
□ Week 3
□ Week 4
□ Week 5
□ Week 6
□ Week 7
□ Week 8
□ Week 9
□ Week 10
□ Week 11
□ Week 12
□ Week 13
□ Week 14
□ Week 15
□ Week 16

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DISCHARGE
□ Discharge DAANES (admin staff)
□ ROI for Aftercare Program
□ Fax Referral to Aftercare Program
□ Relapse Prevention Plan
□ Discharge Summary (completed within 5 days)

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OTHER DOCUMENTATION
□ Calls / emails / messages
□ Treatment Coordination
□ Significant Events (death, illness, breakup, relapse, arrest, hospitalization, etc.)
□ LATE ENTRY – include person-centered reason for delay

 

 

Find the exact 245G language here

 

ASAM 1.0 – OUTPATIENT DOCUMENTATION TIMELINE CHECKLIST

(Copy/paste cleanly into website, EHR, or any text editor.)

Client Initials:__________ Counselor:__________ Intake Day:__________ Admit Day:__________
Highlight = completed by counselor

FIRST 24 HOURS

□ Initial Service Plan (completed by LADC)
□ Mental Health Diagnostic Assessment referral (if indicated)
□ Vulnerable Adult Determination
 □ Individual Abuse Prevention Plan (if applicable)
□ Provide educational material for Opioid Use Disorder (if applicable)
□ Intake Packet (admin staff)
□ MH Intake Form (admin staff)
□ ROI for support person(s)
□ ROI for professional involvement

WITHIN 5 DAYS

□ Comprehensive Assessment
□ Comprehensive Assessment Summary/Update (if original is >30 days old)
□ Assessor signature (same day creation)
□ Collateral call to support persons (optional)
□ Notify legal/probation that client began treatment (optional)

WITHIN 30 DAYS

□ Individual Treatment Plan (client signature or verbal agreement) ONGOING

□ Weekly Individual Session Note (DAP; cover relevant ASAM dimensions)
□ Group Notes (if attending group-based OP services)
□ Treatment Coordination / Collateral Contact Notes (as needed)
□ Significant Events (relapse, crisis, hospitalization, arrest, etc.)
□ Late Entry documentation when required

EVERY 30 DAYS

□ Treatment Plan Review
□ Progress Review (if part of your documentation standard)

DISCHARGE

□ Discharge Summary (within 5 days)
□ ROI for Aftercare provider (if applicable)
□ Referral to next level of care or community supports (fax as needed)
□ Discharge DAANES (if state-required)

 

 

 

Find the exact 245G language here

 

ASAM 3.1 – CLINICALLY MANAGED LOW-INTENSITY RESIDENTIAL

(Recovery residence with clinical support; timelines reflect MN best practice + ASAM guidance.)

Client Initials:__________ Counselor:__________ Intake Day:__________ Admit Day:__________

AT ADMISSION / WITHIN 24 HOURS

□ Initial Service Plan (LADC)
□ Orientation to program rules, expectations, and schedule
□ Vulnerable Adult Determination
 □ Individual Abuse Prevention Plan (if applicable)
□ Suicide / Safety Screening
□ Provide Opioid Use Disorder education (if applicable)
□ Intake Packet (admin staff)
□ ROIs for support persons
□ ROIs for professional involvement
□ MH referral if client does not have an active provider

WITHIN 5 DAYS

□ Comprehensive Assessment
□ Comprehensive Assessment Summary/Update (if original is >30 days old)
□ Collateral calls for support information (optional but recommended)
□ Notify probation/legal where required
□ Initial Nursing/Health Screening (if facility provides)

WITHIN 10 DAYS

□ Mental Health Diagnostic Assessment (if no current DA)
□ Residential Safety Plan
□ Weekly Schedule established (work, treatment, chores, meetings)

WITHIN 30 DAYS

□ Individual Treatment Plan (client signature or verbal agreement)
□ ASAM Multidimensional Risk Update
□ Recovery Environment assessment (housing, supports, legal, CPS)

ONGOING (WEEKLY)

□ Weekly Individual Session Note (DAP with ASAM dimensions)
□ Group Notes (skills, process, health/wellness)
□ Residential Observations / Shift Notes
□ Urinalysis results (if collected)
□ Collateral contacts and care coordination
□ Significant events documentation (relapse, conflict, crisis, discharge planning)

EVERY 30 DAYS

□ Treatment Plan Review
□ Progress Review
□ ASAM Risk Rating Reassessment

DISCHARGE

□ Discharge Summary (within 5 days)
□ Discharge DAANES (admin staff if state-required)
□ Relapse Prevention Plan
□ ROI + Referral to next level of care (OP/IOP/3.5/sober housing/etc.)
□ Aftercare appointment scheduled

 

 

🏥 ASAM 3.5 – CLINICALLY MANAGED HIGH-INTENSITY RESIDENTIAL

(Highly structured, 24/7 staffed residential with intensive services.)

Client Initials:__________ Counselor:__________ Intake Day:__________ Admit Day:__________

UPON ADMISSION / FIRST 24 HOURS

□ Initial Service Plan (LADC)
□ Nursing Assessment (vitals, meds, withdrawal)
□ Suicide Risk Screening
□ Safety Search / Personal Item Inventory
□ Psychosocial screening
□ Opioid Use Disorder educational materials (if applicable)
□ ROIs for supports and professional involvement
□ MH referral if needed
□ Orientation to program rules, expectations, grievance policy
□ Daily Living Needs assessment (food, clothing, meds, shelter)

WITHIN 72 HOURS

□ Full Medical History Review
□ Withdrawal Monitoring (CIWA or COWS)
□ Collateral calls (family, sober supports, legal)
□ ASAM Dimension 1 monitoring and stabilization notes

WITHIN 5 DAYS

□ Comprehensive Assessment
□ Comprehensive Assessment Summary/Update (>30 days old)
□ Assessor signature (same day creation)
□ Residential Safety Plan
□ Medication reconciliation

WITHIN 10 DAYS

□ Mental Health Diagnostic Assessment
□ Integrated Treatment Plan (includes MH + SUD)
□ Recovery Environment Review
□ Legal/CPS contact (if required)

WITHIN 30 DAYS

□ Treatment Plan Review #1
□ Interdisciplinary Case Review
□ Family or Support Session (if applicable)

DAILY DOCUMENTATION

□ Group Notes (skills, process, psychoeducation)
□ Residential Shift Notes / Behavioral Observations
□ Nursing/medical notes
□ UA results (if collected)
□ Daily Progress Note (if part of program standard)

WEEKLY DOCUMENTATION

□ Individual Counseling Session Note
□ Case Management Note
□ ASAM Risk Monitoring (changes in symptoms, withdrawal, readiness)

EVERY 30 DAYS

□ Treatment Plan Review
□ Progress Review
□ Continued Stay Review (ASAM justification)

DISCHARGE

□ Discharge Summary (within 5 days)
□ Discharge DAANES (if required)
□ Final ASAM Multidimensional Risk Ratings
□ Relapse Prevention/Continuing Care Plan
□ Referral to next LOC (3.1, IOP, OP, sober housing)
□ ROI for aftercare and scheduled follow-up appointment

 

 

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