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’.

New Medical Aestheticians who in the past only needed to be able to simply stamp a time and date on treatment forms with occasional side notes, are now expected to correctly chart anything that happens during every patient interaction. In addition to patient charting comes new medical treatment consent forms, HIPPA Forms, photography consent forms, anatomical charting forms, and others.

Medical Aestheticians who have any contact with a patient as any part of their treatment, should be charting everything from follow-up calls, to topical treatments used and the patient’s response, to laser settings, test patch tests, follow up appointments, and the patient’s tolerances to treatments.

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 patient charting so important? Unfortunately, there have been more recent horror stories hitting the media than stories of healing and hope, especially when it comes to medical spa therapies that involve lasers and IPLs. These circumstances are a catalyst of change to medical laser laws across the U.S. Whether the MD is on site or off site, they (along with the medical esthetician) can be held responsible for any legal implications filed by a patient at the hands of a clinician, laser technician, or medical Esthetician.

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.