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Industry News: News

Legal Issues: Patient Charting

Monday, October 2, 2017   (0 Comments)
Posted by: Aly Boeckh
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All medical aesthetic practices and medspas are required to keep detailed medical records for all patients, and those records must be carefully protected. Following is a primer on what should be included in patient medical charts in a medical aesthetics environment as well as some guidelines on how to protect and relay patient information in an environment with multiple providers.

Charting Basics

A properly maintained medical chart should contain the full story of each patient encounter—who the patient is, why he or she came in, what the diagnosis was, and what the treatment plan is. The medical record is critical to ensuring continuity in patient care.

“Professionals need to open up that medical record and be able to discern all the relevant information that they’re going to need in order to make an informed decision as to the course of treatment for whatever the patient approached them for,” explains Jay D. Reyero, partner with national medical aesthetics law firm, ByrdAdatto.

Many state medical boards have rules that dictate what an adequate medical record should contain and, while there may be some differences in minutiae from state to state, these guidelines tend to include certain key items—the patient’s history, identifying information, the diagnosis, supporting documentation, signed consent, any prescriptions given, and any referrals or consultations provided.

In total, a patient chart reflects the administering physician’s professional medical judgment. If the physician deems the information relevant, it is added to the record. There are, however, certain common omissions that make charts significantly less useful, from both a legal and patient care perspective.

Read more at MedEsthetics >>


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