Is your record keeping compliant with best practices?

In this guest blog for Hamilton Fraser, Aesthetic Nurse Software delves into the critical topic of record-keeping compliance, highlighting how adopting advanced digital solutions can help aesthetic practitioners maintain thorough, secure, and compliant records in an increasingly regulated sector.

As medical professionals in the aesthetics industry, recognising the importance of maintaining accurate records and safeguarding confidentiality is crucial. However, unintentional gaps may arise if you store batch numbers, before-and-after photos, consent forms, and medical questionnaires in separate locations or on different devices.

Running your clinic requires significant time and effort to stay compliant, however, by making certain you have a complete and accurate audit trail for each stage of the treatment journey you can protect both you and your patients in the event of any complications.

What are my responsibilities?

Professional bodies including the GMC, GDC and GphC state that the patient records you hold must be effectively protected at all times. Indeed, Section 10 of the Nursing and Midwifery Council’s code states that all qualified practitioners must keep clear, accurate and secure records.

Insurance providers such as Hamilton Fraser state ‘clear notes and photos are the best form of protection when it comes to defending a claim.’

As your practice grows, it can therefore become increasingly challenging to maintain the right level of compliance with paper-based record keeping. This is where specialised software can be invaluable.

Using a paperless system specifically designed for aesthetics provides a clear clinical pathway for each treatment, giving you peace of mind that you have completed all the documentation required once the patient leaves your clinic.

Documenting consultations and informed consent

Medical history should be recorded and reviewed thoroughly prior to any treatment; this can indicate contraindications that may prevent treatment from being suitable and make you aware of any changes since their last visit. ANS can make this super quick and easy by pulling through the patient’s previous answers.

Software, such as Aesthetic Nurse Software, can streamline this process by sending forms to patients before their appointment. This saves time on the day and gives patients the opportunity to thoughtfully and accurately complete their information.

Informed consent means you have explained, and your patient understands, the risks, benefits, and alternatives to a procedure or treatment. This includes possible side effects, reasonable alternatives, and potential outcomes if treatment is declined. The information provided helps patients make informed decisions without overwhelming them. Through ANS, you can store all the consent forms you need for every treatment, all in one place. They can be sent directly to your patient before their appointments, giving them time to thoroughly read the information.

The importance of before and after photos

It’s common practice for insurance providers to require, as a condition of their policy, that before photos be taken with all injectable treatments. For example, Hamilton Fraser explains that without before photos, the policy conditions will not have been met, so the practitioner is running the risk of the underwriters declining to assist if a claim is brought against the policyholder. Hamilton Fraser also strongly advises that is it best practice to take after photos to show the results. Clear notes and photos offer the best protection when defending against a claim.

This emphasises the importance of including before and after photos in your records, making sure you have documented evidence should there ever be a claim made against you. Not only that but if your photos have not been stored securely and they get lost, you may not be covered by your insurance.

Accurate and comprehensive treatment notes

Treatment notes are a critical component of your records. In the NHS there is a saying that ‘If it wasn’t written down, it didn’t happen’ and that applies to medical aesthetics too. The difference is, when you are running your own aesthetics clinic, the responsibility for record-keeping falls on your shoulders, which makes it even more important for this to be accurate and cover as much detail as possible.

Practitioners often struggle with this, especially as their schedules become busier, because it can be time consuming to write comprehensive notes without setting aside extra time after appointments.

Aesthetic Nurse Software addresses this with an innovative feature called ‘Snippets’ that allows you to create quick templates for commonly used paragraphs, allowing you to make sure your notes contain all the important details but also allow you to tailor them to each individual patient’s treatment.

Additionally, using software specifically designed for aesthetics provides a detailed ‘treatment map’ to show exactly which products have been used, and where and how much you have injected or applied, alongside the batch number and expiry dates.

Data security: Making sure your records are stored safely

Storing paper records in locked cabinets within secure premises is essential, but their security relies solely on the physical measures you’ve implemented. Consider the scenario of a break-in—what happens then? Even documents and photos saved on laptops or phones (rather than using cloud-based software) remain vulnerable. What if you lose your device or your computer fails unexpectedly?

For practitioners working across multiple salons, clinics, or even from home, relying on a paper-based system means carrying patient records, consent forms, and stacks of paperwork from appointment to appointment. This increases the risk of forgetting or misplacing critical information, jeopardising patient confidentiality and safety.

In contrast, high-quality cloud-based software offers robust security, and you should be searching for providers that utilise the latest security technology such as TLS (Transport Layer Security). With automatic backups in place, software eliminates the concerns about consent forms being left in your bag or client photos on your phone.

Efficiency: How can you reduce admin to find more time for patients?

Keeping up-to-date records isn’t just about compliance—it’s also about running an efficient business that allows you to focus on providing excellent service for your patients.

So what areas of your aesthetics business can you streamline?

Diary management is a key example. What if a patient calls when you’re at the supermarket? Or during the school run? When you rely on paper systems, you may not have your diary in your pocket for appointment booking—and you certainly won’t have their treatment history to hand to answer any questions.

When you use software that includes mobile access, you essentially have your entire practice at your fingertips at all times—you can access your calendar and records instantly from anywhere, meaning you can accurately answer your patient’s queries.

Some programs, including Aesthetic Nurse Software, also offer online booking to make it even easier for your patients to book an appointment without the need for back-and-forth messaging to arrange.

Software makes it easy to manage and run your clinics, making sure you have everything you need in one place. Consent forms are pre-loaded, so you always have the one you need to hand, and you never have to worry about running out.

You can even send medical questionnaires to patients prior to their appointment, saving you time on the day of treatment and giving you the chance to check their history for any contraindications before they come to the clinic.

Everything is stored centrally and automatically organised into a compliant audit trail. And crucially, because everything is paperless—it’s automatically stored and accessible—you no longer have to waste evenings and days off slaving over admin. You suddenly find yourself with the work/life balance you wanted when you started building your private clinic.

How can you offer an excellent patient experience?

Imagine your patient arrives for their appointment and instead of filtering through mountains of paper to find their record, you simply search for their name on your iPad and their whole history appears in front of you. All their previous appointments, notes, and photos. Giving everything you need to know about the patient in seconds. Did they have any concerns following their last treatment?

This makes it easy for you to build a genuine, long-term relationship with your patients.

Booking process

Your business cannot always be open, and you may not always be available to reply to patients. However, that doesn’t mean your business cannot still be accessible. Using an online booking system gives your customers access to your diary 24/7; it allows them to book their appointments at a convenient time for them, which is often outside of the normal 9-5 working day. It might be after the kids are in bed or whilst they are looking in the mirror brushing their teeth and think, "I need to book my Botox appointment."

Since the pandemic, everyone is much more accustomed to booking online and it is a service that is almost expected to be offered for a business. If you do not offer this service, it could be the deciding factor for a customer to go elsewhere. Your patients want speed and convenience, they want to view the treatments you have to offer and check your availability to book an appointment that suits them. This quick and easy service right from the start can improve your patient’s experience, creating a professional image and reducing any friction.

Keeping in touch

Your patients have busy lives, they have jobs, family commitments, and a social life, meaning they can sometimes lose track of their scheduled appointments, especially if they have been booked months in advance. Think about how you currently communicate with your patients.

With paperless software, you can automate your appointment reminders, which will drastically reduce the number of no-shows you have. Plus, your patients will be grateful to have received a timely reminder about their appointment as they don’t want to miss it.

Sending a follow-up message is also important for providing excellent service. These messages can be used to simply check in with the patient following their treatment, giving them the chance to raise any concerns they may have. This will show the level of care you have about them and their treatment outcome, increasing the likelihood that they’ll want to return.

Going paperless: The most compliant, efficient, and valuable approach

When considering factors like compliance, data security, and administrative management, going paperless provides an easier, safer, and more effective way to run an aesthetics business. Not only does it simplify all aspects of clinic management and admin, but it also saves you precious time and positions you for growth and success.

Another benefit to using a software system is the fact that you are paper-free, meaning that you will be contributing to the sustainability of your clinic by eliminating the need for excessive printing of forms.

The best part? You will be enhancing your patients' experience by offering a proactive and efficient service.

In today’s digital landscape, safeguarding your patients’ sensitive information is paramount, and maintaining data security is essential. Software systems like Aesthetic Nurse Software can help you stay on top of compliance.

Consider implementing the practices mentioned above today and make sure to share this post with others who might benefit from these insights.

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