Patient Charting for Medical Spa Aestheticians

Aestheticians from the traditional day spa environment who are moving into a new medical spa environment have to learn and understand an entirely new way of documenting information as a ‘client’ 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 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.

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 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.

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.

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