Documentation and objectification

As with any medical treatment, everything needs to be meticulously documented in the patient’s file. In addition to documenting the history and examination findings, the therapist needs to make an accurate record of the treatments provided (location, material or active substance mixture, injection technique). At the first consultation, the baseline status is documented by means of a description, photographs (frontal and profile, target zone) and measurements (manually with measuring tapes, rulers and gauges, or using special instruments if available). This enables treatment results to be verified.
Investigative biopsies tend to be unusual in aesthetics but the signed informed consent forms and treatment cost agreements must be stored with the rest of the documentation for ten years. It is a good idea to give patients a printed out ‘before’ picture.
When treating healthy individuals, it is particularly important to ensure that they are provided with comprehensive information which should be more detailed and extensive the more invasive the procedure and should include not only the nature of the chosen procedure (its effects and side effects, risks and special features), but also its expected consequences (e.g. any down-time), the likely duration of its effects and the expected outcome.
It is essential to respect the patient’s wishes and goals. In this context, it is also necessary to determine whether there are any feasible alternatives and what these alternatives are. Patients should also be warned about the off-label use of medicines.
Ensure that all this information is provided on a one-to-one basis and is also in writing which must be signed by the patient. Don’t just hand out a standard form as there is no recourse in this case if anything is disputed later. It is also wise to get the cost sheet signed as well.
Also make sure that you keep a clear and concise record of the session formulating the therapy goal together with detailed information for the patient regarding the courses of the individual treatments, the schedule, the number of sessions and the before-and-after rules. Generally speaking, the more information recorded, the better.