Medical Aestheticians: Medical Spa Patient Charting

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.

Medical Aestheticians who have any contact with a patient as any part of their treatment, should be charting everything from follow-up calls, to topical treatments used and the patient's response, to laser settings, test patch tests, follow up appointments, and the patient's tolerances to treatments.

As a new medical aesthetician, your day spa 'client' files have now been transformed into a legal medical records which could need to stand up in a court of law. Some new medical aestheticians I have spoken with have not yet learned to correctly chart and feel they should not be required to.

Why is it patient charting so important? Unfortunately, there have been more recent horror stories hitting the media than stories of healing and hope, especially when it comes to medical spa therapies that involve lasers and IPLs. These circumstances are a catalyst of change to medical laser laws across the U.S. Whether the MD is on site or off site, they (along with the medical esthetician) can be held responsible for any legal implications filed by a patient at the hands of a clinician, laser technician, or medical Esthetician.

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 a medical esthetician performing medical treatments it's up to you to know what your medical spas requirements are around patient charting and what potential problems exist if you fail to live up to these new requirements.

Medical Spa MD is a medical community of Plastic Surgeons, Cosmetic Dermatologists, and Aesthetic Physicians with more than 4,200 medical spa members. Medical Spa MD offers wholesale Botox online and offers information on nonsurgical cosmetic medical technologies and treatments.

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October 17 2009 03:17 am | Cosmetic Surgery

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