Practice & Compliance
Practice Documentation Audit Worksheet
A self-audit worksheet to help aesthetic practices review documentation completeness. This worksheet is educational — it does not create clinical documentation rules that cannot be verified. Confirm documentation requirements with your state board and qualified counsel.
Last reviewed: 2026-09-17
Patient Identification
- Full legal name and date of birth are recorded.
- Contact information (phone, email, address) is current.
- Emergency contact is documented.
- Preferred communication method is noted.
- Patient ID is consistently used across all records.
Medical History
- Complete medical history is on file.
- Current medications and supplements are documented.
- Allergies and prior adverse reactions are recorded.
- Previous aesthetic treatments and outcomes are noted.
- Pregnancy and breastfeeding status is documented where relevant.
- History of keloids or scarring is noted.
Assessment
- Pre-treatment assessment is documented for each visit.
- Treatment-area assessment is recorded.
- Contraindications are screened and documented.
- Patient goals and expectations are noted.
- Assessment findings support the treatment plan.
Good Faith Exam (When Applicable)
- Whether a Good Faith Exam was required is confirmed for the treatment.
- Date and time of the exam are documented.
- Identity and credentials of the examining provider are recorded.
- Exam findings and assessment are documented.
- Treatment plan or recommendation is noted.
- Whether the exam was in-person or telehealth is indicated (if permitted).
- Patient consent to the treatment plan is documented.
Treatment Plan
- Treatment plan is documented and aligned with the assessment.
- Specific treatment, product, and area are identified.
- Expected outcome is noted.
- Alternative options are discussed and documented.
- Patient consent to the plan is recorded.
Consent
- Signed informed consent is on file for each treatment type.
- Consent includes risks, benefits, alternatives, and expected outcomes.
- Consent for before-and-after photography is documented.
- Consent for telehealth is documented if applicable.
- Date and provider signature are recorded.
Treatment Details
- Date and time of treatment are documented.
- Treating provider name and credentials are recorded.
- Treatment performed and anatomical site(s) are noted.
- Injection technique or device settings are documented.
- Patient tolerance and immediate post-treatment appearance are noted.
- Any deviations from the standard protocol are documented.
Product Information
- Product name, manufacturer, and concentration are recorded.
- Volume or units used are documented.
- Lot number and expiration date are recorded for each product.
- Product sourcing is documented (licensed pharmacy or supplier).
- Compounded product information is noted if applicable.
Lot Numbers
- Lot numbers are recorded for every treatment.
- A lot-tracking log is maintained for recall response.
- Expiration dates are verified before use.
- Product storage conditions are documented.
- Waste disposal is documented.
Treatment Areas
- Anatomical diagram or facial map marks injection or treatment sites.
- Units or volume per site are documented.
- Symmetry notes or asymmetry corrections are recorded.
- Depth or layer of injection is noted where relevant.
- Reference to prior treatment mapping is included for consistency.
Photos
- Standardized before-and-after photos are taken 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.
Provider Identification
- Treating provider is identified in each treatment note.
- Provider credentials are documented.
- If delegation is involved, the delegating provider is identified.
- Medical director or supervising physician involvement is documented where applicable.
- Chart review by the medical director is documented.
Follow-Up
- Scheduled follow-up date and reason are documented.
- Follow-up contact method is recorded.
- Patient-reported outcomes and satisfaction are noted.
- Provider assessment at follow-up is documented.
- Plan for next treatment or maintenance is recorded.
Adverse-Event Documentation
- Date, time, and description of any adverse event are documented.
- Product and lot number involved are recorded.
- Treatment site and technique are noted.
- Patient symptoms and severity are documented.
- Intervention taken is recorded (medication, referral, emergency services).
- Patient outcome and resolution are documented.
- Reporting to FDA MedWatch or manufacturer is documented if applicable.
- Follow-up plan and patient communication are recorded.
Corrections and Amendments
- Chart amendments are documented with date, reason, and author.
- Original entries are preserved (not deleted).
- Corrections are made through the EMR's audit-trail feature.
- Late entries are clearly marked as such.
- Amendments are made in compliance with state requirements.
Record Retention
- Record retention period is established per state requirements.
- Records are stored securely for the required period.
- A records destruction policy is documented.
- Patient record access requests are handled per state law.
- Records transfer procedures are established for practice closure or sale.
Privacy and Security
- 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 vendors.
- A breach-response plan is documented.
- Staff privacy training is documented.
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.