Patient identification
Capture demographics and contact information consistently so each record starts with the same baseline.
Medical history
Record allergies, medications, prior aesthetic treatments, pregnancies, active skin conditions, and contraindications. Update at each visit.
Assessment
Document the clinical assessment that supports treatment — anatomy, candidacy, and any contraindications identified.
Consent
Use written informed consent for each procedure, covering risks, alternatives, expected outcomes, and recovery. Have the patient sign before treatment and store it in the record.
Treatment details
Record the treatment performed, product, dose, sites, technique, and patient response. Use structured templates for consistency.
Product and lot information
Record product name, manufacturer, lot number, and expiration for every injectable. Lot tracking supports recalls and patient-safety follow-up.
Treatment areas
Note the specific areas treated so follow-up and future treatments build on prior care.
Photos where appropriate
Define policies for before-and-after photos: consent, consistent lighting and angles, secure storage, retention, and permitted uses. Treat photos as part of the medical record.
Provider identification
Record who performed the treatment and who provided oversight or delegation.
Follow-up
Document planned follow-up and any outreach. Follow-up records support safety, satisfaction, and complication detection.
Adverse events
Document any adverse event — even mild — with details, response, follow-up, and communication with your oversight provider.
Corrections
Correct errors with a clear amendment process — never delete or overwrite entries. Maintain an audit trail.
Record retention
Retention periods vary by state and record type. Follow your state's requirements and confirm your retention policy matches.
Privacy and security
Patient records are protected health information. Address access controls, backup, breach prevention, and HIPAA obligations. Confirm your EMR vendor has a business associate agreement.
Why an EMR, not a scheduling tool
Generic scheduling tools handle appointments, not medical charting. They typically lack structured intake, consent capture, lot tracking, photo management, adverse-event documentation, and HIPAA-compliant storage. Treating with a scheduling tool in place of an EMR creates real documentation and compliance gaps.