Maintaining Proper Patient Records: A Guide for Aesthetic Practices

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Proper patient record keeping is crucial, yet often overlooked by aesthetic practices. 

Between packed schedules, marketing and daily operations, documentation falls lower on the priority list.

However, poor records open the door to significant risks - improper treatment plans, dangerous medication interactions, increased liability, and jeopardized patient health. Ultimately, inaccurate documentation threatens your practice's reputation and medical license.

Here at Calysta EMR, we understand these challenges intimately. From our years of aesthetics industry experience, we designed features to simplify and optimize documentation workflows specifically for medspas and clinics.

Why Accurate Records Are Vital for Aesthetic Practices

A Medical Doctor Using EMR

As a licensed medical provider, you have legal and ethical obligations to maintain accurate patient health records. This documentation is essential not only for liability purposes, but for providing proper care to your clients.

Complete records allow you and your staff to:

  • Review past medical history, allergy information, health conditions and previous aesthetic treatments. This informs treatment plans and avoids potentially dangerous interactions.
  • Track treatment progress, adverse effects, outcomes and patient satisfaction over time. This data helps optimize future procedures.
  • Seamlessly pick up where other staff left off when handing off patient care.
  • Verify informed consent was obtained. Signed consent forms prove the patient understood risks.
  • Support billing, coding and revenue cycle management activities with detailed documentation on services rendered.
  • Comply with regulations that require medical records be kept for a minimum period.

In the aesthetics field, inconsistent or missing patient records can be particularly risky. Many procedures are elective rather than medically necessary. Some, like Botox injections, can interact with other medications or health conditions. Patients may “doctor shop” and receive the same treatment at multiple clinics.

Thorough records minimize liability risks in these scenarios. They also foster trust and communication between you and your patients. Investing time in proper documentation ultimately protects your practice and your license.

Setting Up an Effective Record Keeping System

A Doctor and Patient Consult

Maintaining accurate records requires an organized system tailored to your administrative workflow and staff responsibilities. Here are some best practices for record keeping in an aesthetic practice:

Categorize Files by Procedure Type

Grouping files by type of treatment, such as Botox, dermal fillers, laser skin resurfacing, etc., makes it easy to locate specific records when preparing for a patient’s appointment. You can even break down categories further, such as injectables for the upper face (Botox, fillers) vs. lower face (lip enhancements, marionette lines).

Standardize Documentation Forms

Creating templates, forms and checklists guides your team to consistently document the key details. Important elements include:

  • Patient information and demographics
  • Medical history, including conditions, medications and allergies
  • Details of aesthetic assessment and treatment plan
  • Informed consent documentation
  • Procedure notes, including products/devices used and practitioner information
  • Adverse events or complications
  • Post-procedure instructions provided
  • Follow-up notes on healing, results and patient satisfaction

Centralize Records Storage

Consolidating records in one electronic health record (EHR) system makes them accessible to any staff member involved in the patient’s care. Digital storage also enables remote access and backups to prevent loss. Options include:

  • Scanning paper charts to create electronic copies
  • Utilizing secure cloud-based storage platforms
  • Investing in EHR software designed for aesthetic practices, like Calysta

Digitize Intake Forms

Digitizing forms like medical history questionnaires and consent forms enables more accurate documentation that patients can complete before appointments. This frees up time for treatments. 

Schedule Regular Chart Audits

Periodically review a sample of your patient records to catch any documentation gaps. Identify areas for improvement in your forms, templates or filing system based on what information is missing.

Leveraging Solutions like Calysta EMR

While the above strategies will help you implement a strong record keeping system, juggling the administrative side of an aesthetic practice leaves little time for optimizing workflows. That’s where a purpose-built solution like Calysta EMR comes in.

Our innovative platform completely automates and streamlines patient record keeping by:

HIPAA-compliant, securely accessible electronic chartingProtects patient data
Pre-made templates and formsStandardization for accuracy
Embedding documentation into appointment schedulingSeamless workflow integration
Digitizing forms for online patient completionSaves appointment time
Automatic saving of documentation to patient chartEnsures completeness
Follow-up remindersCaptures outcomes
Secure cloud backupAccessibility without loss

Everything is accessible via desktop or our mobile app for on-the-go convenience. Our aesthetic-specific features like procedure price lists, before/after galleries, and cosmetic injection logs save you time.

The Bottom Line

A Doctor and Patient Consult

With Calysta EMR, documentation and records management is streamlined, simplified, and optimized for your unique aesthetic practice needs. Why not see for yourself? Contact us today to request a demo and discuss bringing effortless record-keeping to your practice.

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