Patient Record keeping
Patient record keeping for your patients is an art but does not need to be difficult. Here are our best tips that will benefit you and your patient during and especially after a treatment.
In many cases an informative and well written record from a consultation or a treatment can give you good support in your daily work. This includes reminders for details that are very specific. As a team a well-documented record is essential and a very powerful tool for your patients. Make things easy for your colleagues by taking notes of the patient thoughts, challenges and goals with each treatment.
A good record can help you to be emphatic to patient sensitive subjects. A well written minute can also help to clear up misunderstandings, explain certain damages and even conflicts. Remember that a patient record can be very useful during legal processes and for insurance claims.
We recommend that you spend some time during each patient treatment and make a thorough documentation. Here are our recommendations:
1. Date of treatment
This seems very logical and is crucial for follow-ups. For many EMR or online records, like MERIDIQ, this is saved automatically on the day for the recording. There are also instances when you need to record changes or exact time for prescribing a specific medication. This is especially important if someone would have an allergic reaction.
2. Patient incentive
What thoughts and desires does the patient have for each treatment. To have this in writing can be very valuable during the whole treatment process. A well-documented goal helps you and your patient to keep focus and motivation for why they seek your help. Let your patients help you by writing down their preferences and expectations. Read up on the MERIDIQ registration portal, that does just that.
3. Your expert opinion
It is appropriate to give detailed anatomical, your own expectation and goals with the treatment. Important to document asymmetries, skin abnormalities or other relevant observations that can have importance in the future.
4. The patient record consent
What did you and your patient agree on? Does the patient understand the dynamic of the treatment? Did the client understand that there is a need for continuous follow ups for the upkeep of the results? Indication there is a purpose for follow up treatments.
5. Actual treatment
This is the main point that concerns all treatment specific details that can ease the analysis of the result, upkeep, or corrective treatments. Document everything for what treatments has been conducted, settings on machines, time of care, products used, amount of filler and depth of needles used etc. All details that can help you and your colleagues replicate a successful treatment.
6. Thorough patient records descriptions
Indicate exact areas that has been treated. Using an EMR or online record system like MERIDIQ, this can be done on an actual image of the patient. Using tools like a paint brush to show the areas for injections or other treatments done. You can use different colors to separate different products or depths. This avoids confusion and gives better precisions for further and/or corrective treatments.
7. Prices
Final prices are very good to keep in the record as this can very a lot for combinational treatments, discounts and other package deals.
8. Aftercare advice
That the patient has actually received aftercare advice should also be reflected in the records. It can also be good to write down any information you have passed on regarding any signs and symptoms that should lead to a contact with you or the health care.
9. Images
We rely on good documentation for good imagery before a treatment. This is often good to use as comparison with photos after the treatment. Images like this is great to use for educational or marketing purposes. However, it is very important that you get your patient consent before using any of these images.
10. Next steps
A good idea is already during the treatment, document what you have discussed for what the next steps are. It is professional to have the full customer journey in the record, as clients will come back for follow-ups. This will also help you to remind patients to when they should book their next visit.
Good luck with you record keeping! Please contact us if you want more information on how you can use MERIDIQ to simplify your daily documentations.