Best Practices for Medical Record Retention for Med Spas

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Hospitals, rehabilitation centers, and similar “functional” institutions are used to implementing EMRs (electronic medical record) to improve their healthcare services. With the multiple benefits this system can offer, there’s no reason why aesthetic clinics and medical spas can’t follow suit. 

So what are some things med spas should keep in mind for medical record retention? The most important thing would have to be the record retention period. This varies per state: New Jersey has a minimum 8-year retention period, while other states such as California, have more nuances to keep in mind.

Understanding this, above all, ensures that your aesthetic spa is compliant with policies regarding medical record retention. 

Are Aesthetic Clinics Allowed To Retain Medical Records? 

By achieving HIPAA compliance, your clinic becomes a covered entity which means you’ll be legally allowed to hold health care records and retain medical information on behalf of your clients. 

With an EMR system, you can implement medical record retention for your practice and enjoy the benefits of using an EMR, including: 

  • Seamless documentation
  • Faster transaction times
  • Reduced overhead
  • Improved customer service 
  • Improved scheduling
  • Continuity in service 

What Medical Data Can Your EMR Retain? 

Think of the EMR as the ultimate knowledge hub for each and every patient. As a medical spa the turnover of patients can be very high. Working with multiple new clients getting different services and products done on a regular basis can be confusing for you and your team. 

With an EMR, your practice can eliminate the use of a paper record and store your patient’s medical record digitally. Here are just some of the health information you can retain: 

1. Personal identification information

This includes private information such as their name, age, birthdate, and ethnicity. This also includes their social security numbers, addresses, information about their healthcare provider, and similar data. Some EMR platforms are equipped with online payment features that allow patients to pay for appointments using major credit cards, which might be cached on the system for easy checkouts. 

2. Medical history

An EMR can store a patient’s comprehensive medical history. With this, physicians and even aestheticians can have a holistic understanding of the patient’s medical needs -- from immunization shots to hospitalizations to previous appointments -- within that clinic. 

With an EMR, patient records are limited to one clinic, practice, or hospital only. An EHR (electronic health record), on the other hand, shows patient medical records on a grand scale, often involving multiple physicians, specialists, and institutions. With an EHR, various practitioners are able to access old medical records even after the patient's discharge from a certain facility. 

In comparison, EMR’s more simple features are better suited for a growing aesthetic practice. More importantly, this takes the guesswork out of providing good service. Incompatibility with services and products, allergic reactions, typical side effects experienced, and other client notes can be stored here to keep aestheticians in the loop. 

3. Family medical history

Knowing a patient’s family medical history is essential in providing optimal service. With this information, your clinic can keep your patients safe by matching them with compatible treatments only. 

Family medical history provides insight into what your patient may or may not respond to, which could be especially beneficial for holistic wellness clinics. For instance, a patient with chronic immunodeficiency issues in the family might benefit from regular vitamin C IV drips. In another example, a patient with a history of early onset hormonal imbalance is a prime candidate for hormone replacement therapy. 

Naturally, this extends beyond wellness programs. A patient with a history of obesity in the family could help your team understand how to personalize a treatment for them and match them up with the most suitable body contouring procedure. 

Knowing these things is key to helping every patient achieve their best, whether it’s for a laser procedure or a weight loss program. 

4. History of bookings and appointments

On top of medical records,  EMRs may also retain a history of bookings and appointments. For instance, Calysta is equipped with a scheduling tool, allowing clinics to keep track of their appointments. 

This allows your team to see the day-to-day workflow and get a reliable database of previously booked appointments and consultations. Additional features such as document and photo storage, as offered by Calysta, can help medspa practices keep track of more than just booking dates; with this, aestheticians could upload before and after photos, keep physician notes, and other information on the patient’s medical record. 

5. Medication history 

One of the more crucial information offered by an EMR is a patient’s medication history. Some injectables, for instance, are advised against patients taking certain medications. By having an understanding of what medications your patients are taking, your aestheticians are able to use your patient's medical record to ensure no complications arise. 

Why Your Aesthetic Spa Should Consider Medical Record Retention

Shot of a doctor having a consultation with a patient

Your clinic might not be a medical practice but adopting an electronic medical record system could boost your sales and improve conversions. As mentioned earlier, having an EMR offers benefits beyond better documentation. These include: 

  • More consistent service: If your clinic has a rotating roster of aestheticians, having an EMR means your clients don’t have to undergo a consultation every time they work with a new aesthetician or physician. With just the EMR, any practitioner on your team can provide a consistent level of service and know what your patient expects just by looking at their patient’s record. 
  • Digital storage of consent forms: In the cosmetic and surgical industry, consent forms are necessary medical records and are a requirement before a patient can proceed with any treatment. Calysta allows practices to send consent forms which patients can sign electronically. These forms can be stored on the cloud for easy access and added to the patient's record.

How Long Can Medical Records Be Retained? 

Understanding the medical record retention requirements can help your aesthetic practice navigate privacy laws and ensure that your clinic stays compliant with the HIPAA. 

As a covered entity, your practice will be expected to uphold the same rules as any health care provider, including the observance of any medical record retention policy, especially ones concerning the retention period. 

The good news is that it’s pretty straightforward. HIPAA regulations don’t have a set records retention period because this varies from each state and depending on the law a certain procedure or treatment falls under. In New Jersey, medical records should be protected against loss, destruction, or unauthorized use for at least seven years. In California, specific rules outline a three-year retention period while other health services require healthcare institutions to preserve medical records for a minimum of seven years following a patient’s discharge. 

We recommend that you learn the medical record retention law for your specific state to understand your obligations regarding record retention schedule. 

How Can I Keep My Medspa’s Medical Records Safe and Compliant? 

In truth, medical record retention isn’t as complicated as it sounds. Here are two things you should look into to keep your clinic away from most liabilities: 

  • Secure an agreement with your third-party provider: If you’re hosting patient information using a third-party service, enter an agreement where they delete patient records after a certain period of time to avoid any HIPAA violations. 
  • Work with a secure EMR provider: Most importantly, seek out an EMR platform with robust security measures. Work with a reliable team that can safeguard your patients’ crucial information, whether you’re serving a minor patient or an adult patient. Cybersecurity hackers prying into private information are just as menacing as HIPAA violations. 

Ultimately, it all boils down to finding a good EMR provider. Make sure that the team behind the platform has a proven experience of running an aesthetic clinic so you’ll get a better insight on retention policies and compliance specific to cosmetic spas. 

Schedule A Two-Week Trial Today, For Free 

Calysta is the first-of-its-kind EMR platform designed specifically for aesthetic spas. Developed by Dr. Hardik Soni, head of Ethos Spa and the popular NJ Center for CoolSculpting, this platform is built to help cosmetic clinics and practices of all sizes thrive and provide a better level of care for their clients. 

Not sure if your clinic is eligible to store medical records? Get in touch with us today to book a free two-week trial. 

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