Patient Charting for New Laser Clinic Aestheticians
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Aestheticians from the traditional day spa environment who are moving into a new medical spa environment have to learn and understand an entirely new way of documenting information as a ‘client’ transforms into a ‘patient’.
New Medical Estheticians who were used to simply stamping a time and date on treatments with occasional side notes, are now expected to chart anything and everything they say and do during a patient’s entire treatment. In addition to patient charting comes new treatment consent forms, HIPPA Forms, photography consent forms, payments, agreement forms, anatomical charting forms, and more.
Anyone who has contact with a patient, in immediate regards to their treatments, should be charting everything from follow-up phone calls, to letters mailed, to topicals used and the patient’s response, to laser settings and the patient’s response, patch tests, follow up appointments, and patient’s tolerances to therapies.
The once client file has now transformed into a medical record by all standards which could stand up in a court of law. Some aestheticians I have spoken with have not learned the art of charting and feel they should not be required to do so.
Why is it so important you ask? Unfortunately, there have been more horror stories hitting the media than stories of healing and hope, especially when it comes to therapies that involve lasers. These unfortunate circumstances are a catalyst of change to laser laws across the U.S. Whether the MD is on site or off, they (along with the therapist) can be held liable for any legal implications filed by a patient at the hands of a clinician or aesthetician.
While it may seem harsh, even the most skilled and brilliant esthetician should be terminated if they refuse to properly chart and document a patient’s care. The rule of thumb is just this… if you didn’t chart it, it didn’t happen.
If you’re performing medical treatments it’s up to you to know what your facility’s requirements are for charting, and what implications can arise if you fail to comply.
Medical Spa MD is a cosmetic medical community of Plastic Surgeons & Cosmetic Dermatologists with more than 4,200 medical spa members. Medical Spa MD offers medical esthetician training manuals and offers information on nonsurgical cosmetic medical technologies and treatments.
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