Patient Charting for Plastic Surgery Medical Spa Estheticians

Free downloads and more information for medical estheticians is available at Medical Spa MD, a fast growing community of Plastic Surgeons, Dermatologists and Aesthetic Physicians with 2,000+ Physician Members worldwide.

Estheticians coming from the traditional day spa industry into the medical spa environment have to learn and understand an entirely new way of documenting information as a 'client' transforms into a 'patient'. New Medical Aestheticians who in the past only needed to be able to simply stamp a time and date on treatment forms with occasional side notes, are now expected to correctly chart anything that happens during every patient interaction. In addition to patient charting comes new medical treatment consent forms, HIPPA Forms, photography consent forms, anatomical charting forms, and others. Medical Estheticians who have contact with a patient as any part of their treatment, should be charting everything from follow-up phone calls, to letters mailed, to topical treatments 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 esthetician could 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.