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« Paula D. Young RN joins Medical Spa MDs Editorial Staff | Main | Medical Spa MD: The 6 best ways to earn and use patient testimonials, associations, and third party endorsements. »
Saturday
Feb282009

Medical Spa Estheticians: Charting (or not charting) Your Termination Notice

Many aestheticians coming from the day spa industry into the medical spa environment have to learn a whole new way of documentation as a client now transforms into a patient.

Aestheticians who are used to time and date stamping treatments with occasional side or progress notes, now are expected to chart everything they say and do during a patient’s treatment. Along with charting comes treatment consent forms, HIPPA Forms, photography consent forms, payment agreement forms, anatomical charting forms, etc.

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.

Harsh as it may seem, and it has even happened to our practice, even the most skilled and brilliant aesthetician could be terminated if they refuse to properly chart a patient’s care. Our rule of thumb is... if you didn’t chart it, it didn’t happen.

I’m interested to know what your facility’s requirements are for charting, and what implications can arise if you fail to comply?

Author: Paula D. Young RN runs internal operations and training at Young Medical Spa and is the author of the Medical Spa Aesthetics Course and Advanced IPL & Laser Training course for medical estheticians and laser technicians.

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Reader Comments (8)

I've worked in a 'medical spa franchise' that was little more than a day spa with a doctor we never saw and the only paperwork that anyone worried about was the sales forms and quotas. I left after a few months and I'm still looking for a reputable plastic surgeon or dermatologist who values my skills. I want to help others and, although I'm not a doctor, I'm not dumb either. When I find a medical spa that fits, I'll strive to be the best employee they could ask for.

And that's the other end of the spectrum! Good for you for taking the high road! The term "Medical Spa" is a big grey area... but it's funny how black and white it can be in the court of law.

I am a midlevel who worked at a medispa and was shocked when I looked at the esthetician's notes. I tried to "teach" her but she acted (at times)like she knew more than me. Needless to say, I did not remain at that place for very long!
Attitude, attitude, attitude...

03.1 | Unregistered CommenterFiona

Paula, is there a chart template with a checklist to insure proper notes? My notes on clients are good, I transfer all notes to the computer, but I don't want to miss something that needs noted.

Bridget,
There is no "standard" template as I know it. This would be a great forum for physicians, clinicians and aestheticians to share. Because the services offered at medical spas vary greatly, process forms are designed to accommodate specific procedures.

I know at our practice, we have checklists for body sculpting (i.e., SmartLipo, SlimLipo & VASER Lipo), another for Lux2940 Fractional Skin Resurfacing, another for Laser Hair Reduction, another for VelaShape and Injectables, etc. We have pre-packets made up ahead of time for various therapies, then pull the specific packet into a patient's chart when they come in for that procedure. We also have separate check lists for payment and financing.

We also use two different color folders for patients: red for body sculpting and blue for medical spa services (i.e, injectables, laser services, spa services, etc.). It's not uncommon for our patients to have two folders each. We have not progressed to EMR and still prefer the paper trail!

Sounds like a lot of papers, but we try to make sure we have everything covered! With personnel coming and going, it's reassuring to know that everyone follows the same process regardless of their position within our medical spa.

If all else fails, you always have S.O.A.P. (Subjective, Objective, Assessment, Plan). It's tried and true. Easy to use and remember. Hope it helps.

03.14 | Unregistered Commenterjillanne

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I recently purchased a small "medspa". We do facials, body contouring, fascia blasting, etc. But we also do laser hair removal (IPL) and RF facials. I have been slowing upgrading our client intake forms and updating procedures. The one thing I cannot find are charts for recording laser treatments? The ones currently at the spa are very minimal and really just include a picture of the body to mark an "X" in the spot treated and a place to write in the settings. Surely there is something better out there? Would anyone be willing to provide go by forms?

I have been able to find all manner of client consent forms on line, as well as pre and pot treatment forms, but nothing chart the laser, ipl or rf treatment as a matter of record.

I'd take any help that you're willing to provide.

.

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