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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