What should you include in your Patient Records as a Practitioner?

Top Ten Things to Document and Include in Patient Records as a Practitioner

Keeping patient records is an art, but it doesn’t have to be complicated. Here are our top tips for including information that you and your patient can benefit from, especially after a treatment. In many cases, detailed notes from the consultation and treatment can provide support in your daily work – you can remind yourself of relevant and very specific details.

If you work in a team, meticulous record-keeping is invaluable – a fantastic tool for communicating with your customer. Make it easier for your colleagues to take care of your customer in the best way possible by understanding their thought processes, challenges, and goals.

A patient record can help you show empathy and valuable attention to patient-specific subjects. Detailed notes can also be the basis for resolving any misunderstandings, explaining injuries that have occurred, or even conflicts. Keep in mind that patient records can be useful evidence in legal proceedings or insurance matters.

We recommend that you make an effort to tailor each unique visit to the patient’s needs and preferences and document this.

1.     Date of Treatment

This may seem incredibly basic – and it is. In MERIDIQ, the date is automatically recorded when you register a visit. There are also occasions when you should supplement this with the exact time of a given medication (for example, in the case of urgent treatment for an allergic reaction or enzyme treatment with hyaluronidase to relieve one of the few more serious side effects after a hyaluronic acid injection treatment).

2.     Patient’s Motivation

What the patient desires, thinks, and ponders before the performed treatment. Having in writing what the patient is thinking can be of great value throughout the treatment process and ensures that you don’t lose focus on the patient’s motivation for seeking your help.

3.     Your Expert Assessment

It is appropriate to provide detailed anatomy and your own expectations and goals for the treatment. It’s important to mention asymmetries, skin changes, or other relevant observations that may be significant in the future.

4.     Agreement

What did you agree on together? Does the customer understand that a treatment process is dynamic? Has the customer understood that it is necessary to maintain certain treatments for sustained results? A note about this can indicate the purpose of maintenance.

5.     Performed Treatment

This point covers all treatment-specific details that can facilitate the analysis of treatment results, maintenance treatments, or corrective treatments. Document everything from the specific treatment performed, settings for machine treatments, duration of acid treatments, products used, filler or toxin quantities, needle depths used in microneedling, etc. All details that can help guide you or a colleague to replicate a successful treatment.

6.     Precision in Description

Specify the exact treatment areas. You can use the fantastic feature of marking the location of your treatment in MERIDIQ. You can use different colors to indicate different products or distinguish different depths. In the journal text, you can add details such as depth and technique (e.g., cannula or sharp needle, in filler injection treatments). This avoids confusion and provides better accuracy in corrective treatments if needed.

7.     Prices

You can enter preset prices when specifying a specific treatment, but these can vary, so it may be wise to add if the customer received package offers or any unique discounts.

8.     Aftercare Advice

Document that the patient has received aftercare advice that they should follow. It may also be good to specify that you informed them about symptoms that should prompt them to contact you or medical professionals.

9.     Photos

We rely on good documentation in images before a treatment. In MERIDIQ, the patient can indicate whether they approve of photos being published, including on social media. For example, if the customer only approves the use of treatment photos for educational purposes or meetings with colleagues, this can be stated in the journal. Remember that the customer needs to consent to the publication of photos before each specific treatment in MERIDIQ – this allows the patient to have a choice for each unique visit.

10.  Future Plans

A significant advantage is that the next steps for the patient’s aesthetic journey are evident in the journal if you have discussed this. It is professional to have full control of patients’ journeys when they return for follow-up visits and beneficial for you and your colleagues to understand your thought processes.

Good luck with your record-keeping, and feel free to contact us for more tips on how to use MERIDIQ in your daily record-keeping. If you haven’t already tried the record-keeping system, get started now with just a click below!