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 Estheticians who were used to simply stamping a time and date on treatments with occasional side notes, are now expected to chart anything and everything they say and do during a patient’s entire treatment. In addition to patient charting comes new treatment consent forms, HIPPA Forms, photography consent forms, payments, agreement forms, anatomical charting forms, and more.

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 medical patient charting so important? Unfortunately, there have been a number of recent horror stories hitting the media, especially when it comes to medical spa therapies that involve lasers and IPL treatments. These media reports are a catalyst of change to medical laser laws across the U.S. Independent of whether the MD is on site or off site, they (along with the medical esthetician) can be held legally responsible for any law suits 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 performing medical treatments it’s up to you to know what your facility’s requirements are for charting, and what implications can arise if you fail to comply.

Medical Spa MD is a cosmetic medical community of Plastic Surgeons & Cosmetic Dermatologists with more than 3,500 physician members. Medical Spa MD offers medical esthetician training manuals and offers information on non-surgical cosmetic medical technologies and treatments.

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