Patient Charting For Medical Spa Estheticians

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’.

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.

Estheticians ‘client’ files have now been transformed into a legal medical records by all standards which could need to stand up in a court of law. Some estheticians I have spoken with have not learned the art of charting and feel they should not be required to.

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.

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 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.