Practice Management
Aesthetic Documentation Checklist
A practical reference for the documentation elements an aesthetic practice should capture and maintain. This checklist helps providers evaluate whether their documentation system supports safe, compliant recordkeeping. It is educational and is not legal or medical advice.
Last reviewed: 2026-08-04
Patient Demographics
- Full legal name and date of birth.
- Contact information (phone, email, address).
- Emergency contact.
- Preferred communication method.
- Insurance information if applicable.
Medical History
- Complete medical history including chronic conditions.
- Current medications and supplements.
- Allergies and prior adverse reactions.
- Previous aesthetic treatments and outcomes.
- Pregnancy and breastfeeding status where relevant.
- History of keloids or scarring.
Good Faith Exam Documentation
- Date and time of the Good Faith Exam.
- Identity and credentials of the provider who performed the exam.
- Exam findings and assessment.
- Treatment plan or recommendation.
- Whether the exam was in-person or via telehealth (if permitted).
- Patient consent to the treatment plan.
Treatment Notes
- Date and time of treatment.
- Treating provider name and credentials.
- Treatment performed and anatomical site(s).
- Product name, concentration, and volume used.
- Lot number and expiration date of each product.
- Injection technique or device settings.
- Patient tolerance and immediate post-treatment appearance.
- Any deviations from the standard protocol.
Consent
- Signed informed consent for each treatment type.
- Consent includes risks, benefits, alternatives, and expected outcomes.
- Consent for before-and-after photography.
- Consent for telehealth if applicable.
- Date and witness signature.
Photos
- Standardized before-and-after photos with consistent lighting and angles.
- Photos are labeled with patient ID, date, and treatment area.
- Photo consent is documented.
- Photos are stored securely with access controls.
- Photos are linked to the corresponding treatment record.
Product and Lot Tracking
- Product name, manufacturer, and lot number recorded for every treatment.
- Expiration date verified before use.
- Product sourcing documented (licensed pharmacy or supplier).
- A lot-tracking log is maintained for recall response.
- Compounded product information is documented if applicable.
Treatment Mapping
- Anatomical diagram or facial map marking injection or treatment sites.
- Units or volume per site documented.
- Symmetry notes or asymmetry corrections.
- Depth or layer of injection where relevant.
- Reference to prior treatment mapping for consistency.
Follow-Up
- Scheduled follow-up date and reason.
- Follow-up contact method (in-person, phone, message).
- Patient-reported outcomes and satisfaction.
- Provider assessment at follow-up.
- Plan for next treatment or maintenance.
Adverse-Event Documentation
- Date, time, and description of the adverse event.
- Product and lot number involved.
- Treatment site and technique.
- Patient symptoms and severity.
- Intervention taken (medication, referral, emergency services).
- Patient outcome and resolution.
- Reporting to FDA MedWatch or manufacturer if applicable.
- Follow-up plan and patient communication.
Protocol Access
- Current treatment protocols are accessible to all providers.
- Protocols are version-controlled with review dates.
- Protocol deviations are documented and justified.
- Medical director sign-off is recorded on protocols.
- Protocols are reviewed and updated at a defined interval.
Chart Review
- Chart-review schedule is established with the medical director.
- Review findings are documented per chart.
- Deficiencies are communicated to the provider.
- Corrections are tracked to completion.
- A chart-review log is maintained.
Reporting
- Monthly or quarterly reports on treatments, products, and outcomes.
- Adverse-event reports are compiled and reviewed.
- Inventory and product-usage reports for cost tracking.
- Provider productivity reports if applicable.
- Compliance or audit reports as needed.
Privacy
- Access controls limit who can view and edit patient records.
- Audit logs track who accessed each record.
- Data is encrypted in transit and at rest.
- Business Associate Agreements are in place with the EMR vendor.
- A breach-response plan is documented.
Access Controls
- User roles and permissions are defined (provider, staff, admin).
- Each user has a unique login — no shared credentials.
- Access is revoked promptly when staff leave.
- Password policies are enforced.
- Two-factor authentication is enabled if available.
Multi-Provider Workflows
- Multiple providers can document independently in the same system.
- Patient records are shared across providers with appropriate access.
- Cross-coverage documentation is supported.
- Provider schedules and assignments are tracked.
- Handoff notes are supported for shared patients.
Your Next Step
Ready to take the next step?
Use this checklist alongside the relevant NOVI support options. Requirements vary by state, license and practice structure — confirm specifics with qualified guidance.
NOVI resources are provided for general educational purposes and are not legal, medical, tax, financial, licensing, or regulatory advice. Requirements may vary by state, provider credentials, practice structure, and services offered. Current requirements should be confirmed with qualified professionals and official regulatory sources.