Medesthetics

OCT 2017

MedEsthetics—business education for medical practitioners—provides the latest noninvasive cosmetic procedures, treatment trends, product and equipment reviews, legal issues and medical aesthetics industry news.

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LEGAL ISSUES | By Alex R. Thiersch, JD 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 ap- proached them for," explains Jay D. Reyero, partner with national medical aesthetics law fi rm, 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, sup- porting documentation, signed consent, any prescriptions given, and any referrals or consultations provided. In total, a patient chart refl ects 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 signifi cantly less useful, from both a legal and patient care perspective. COMING UP SHORT Lack of documentation of informed consent is one of the primary shortcomings in medical records. Generally speaking, physicians need to show that they have followed the standard of care by fully informing a patient about the risks and potential complications of the course of action they are recommending. "Documentation of informed consent is critical to de– fend yourself," Reyero says. "Whether it's malpractice litigation or a medical board complaint issue, these are the most important documents you have to show that you advised the patient, as much as possible, as to what you were going to do, and that the patient consented to the procedure performed." 22 OCTOBER 2017 | Med Esthetics © GETTY IMAGES Patient Charting Meticulous patient charting protects both patients and providers. Here's what you need to include.

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