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The Psychotherapy Documentation Primer

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About the Course

Everything a therapist needs to know to record client intake, treatment, and progress. It fully incorporates the latest managed care, accrediting agency, and government regulations.

Note: This is for the 2nd edition. The 4th edition is due to be released in December 2020. An updated course will be published when the 4th edition is released.

This course is based on the book, The Psychotherapy Documentation Primer created by Donald E. Wiger, Ph.D. in 2005.

Publication Date:

2nd Edition, 2005

Course Material Author

Donald E. Wiger, Ph.D.
Dr. Wiger, a psychologist, runs a large mental health clinic in St. Paul, Minnesota, and is an adjunct professor at Argosy University, The Minnesota School of Professional Psychology. He is the author of numerous books.

Donald E. Wiger, Ph.D. authored the material only, and was not involved in creating this CE course. They are identified here for your own evaluation of the relevancy of the material this course is based on.

Recommended For:

This course is recommended for health care professionals, especially addiction counselors, psychologists, mental health counselors, social workers, and nurses who seek knowledge about clinical record keeping. It is appropriate for introductory to intermediate levels of participants' knowledge.

Course Objectives:

After taking this course, you should be able to:

  1. Discuss the purpose and steps involved in conducting a biopsychosocial assessment
  2. Discuss current documentation procedures and third-party requirements
  3. Provide an effective mental status exam
  4. Describe important aspects of the diagnostic interview
  5. Discuss aspects of "good" treatment plans and "bad" treatment plans
  6. Discuss what constitutes a "good" progress note
  7. Describe the process for documenting the need for additional services

Disclosure to Learners

Disclosure of Relevant Financial Relationships

CE Learning Systems adheres to the ACCME's Standards for Integrity and Independence in Accredited Continuing Medical Education. Any individuals in a position to control the content of a CE activity – including faculty, planners, reviewers, or others ― are required to disclose all relevant financial relationships with ineligible entities (formerly known as commercial interests).

The following relevant financial relationships have been disclosed by this activity's planners, faculty, and the reviewer:

Planners and Reviewers

The planners of this activity have reported that they have no relevant financial relationships.

Commercial support

There is no commercial support for this distance-learning course.

Exam Questions

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  • What do I have to do to complete the course?

    To complete the course, review the course objectives, then review the material, and then pass the exam with a score of 75% or greater and lastly complete an evaluation.

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Course Retired
Course Number 100271
6 CE credit hours
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Exam Fee $35.82
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