Written and Photographic Documentation

The Patient File

  • All written patient communication is safely stored in accordance with APPs.

  • Can be hardcopy (rare) or electronic within the patient management system.

  • Should contain:

    • Contact details

    • New Patient Questionnaire (NPQ) / medical history

    • Consultation and progress notes

    • Consent forms

    • Photos

    • Prescriptions (if applicable)

  • Information such as sales of products may not necessarily sit in the patient file but should be accessible.

New Patient Questionnaire (NPQ)

  • Completed by patient before or at the first appointment.

  • Asks about:

    • Medical history

    • Previous cosmetic treatments

    • Current medications

    • Lifestyle factors

  • May also include a privacy statement and photo consent.

Initial Consultation Notes

  • Includes:

    • Informed consent

    • Test patches (if applicable)

    • Cosmeceutical products recommended/purchased

    • Photos (may be taken)

    • Other applicable information, e.g., allergies

    • Next appointment date

  • Documented at the patient’s first consultation, covering:

    • Patient’s concerns

    • Background, details, and/or contributing factors to these concerns

    • Treatment options discussed/recommended

    • Treatment plan

    • Information provided, i.e., pre/post instructions

Consultation Notes: Example #1

  • 21/03/21 - James attended to discuss mildly atrophic post-acne scarring on his cheeks.

  • James hasn't had active acne for 10+ years.

  • Discussed ablative and non-ablative laser resurfacing and skin needling.

  • James previously tried 3 skin needling sessions 12 months ago with no improvement.

  • Recommended a course of 3 non-ablative laser resurfacing treatments at 6-week intervals due to James' preference for minimal downtime.

  • Treatment information, informed consent, and pre/post-treatment information provided.

  • Recommended James prepare his skin with cosmeceuticals XYZ.

  • Booked first treatment in 4 weeks.

Consultation Notes: Example #2

  • 22/01/21 - Charmaine sought lip augmentation, having no prior filler treatments.

  • She desired a natural look, aware of slight asymmetry in her lower lip.

  • Discussed using 0.6 mls of Belotero Lips Contour, mainly in the upper lip, with some to correct lower lip asymmetry.

  • Treatment information, informed consent, and pre/post-treatment information were provided.

  • Pre-treatment photos taken.

  • Charmaine proceeded with the treatment after consultation/prescription by Dr. Oates at 10.15 am.

  • See progress notes for treatment details.

Patient Progress Notes

  • Document the treatment details after the treatment has been performed.

  • Includes:

    • Products and/or equipment used

    • Doses and/or parameters used

    • Patient response/reactions

    • Clinical endpoints

    • Follow-up appointment date

Patient Progress Notes: Example #1

  • 21/04/21 – James advised he’s been adhering to all pre-treatment instructions.

  • Pre-treatment photos taken.

  • James viewed the topical anaesthetic (TA) video and signed the TA consent form.

  • Prepped skin with cleanser and alcohol swabs, applied TA, and left for 30 mins.

  • Treated full face using Fraxel on 1500nm, 15mj, level 5, 8 passes, plus an additional pass on scars.

  • Skin was quite reactive but settled after 10 mins of cold compresses.

  • Gave James post-treatment products for the next 7 days and pre/post-treatment instructions.

  • Next appointment scheduled in 6 weeks, with a follow-up call in 2 days.

Patient Progress Notes: Example #2

  • 22/01/21 - Charmaine had 0.6 ml of Belotero Lips Contour injected for lip augmentation and asymmetry correction.

  • 0.4 mls injected into the body of the upper lip for volume, and 0.2 mls in the border of the lower left lip to correct asymmetry.

  • Patient coped well with Rx, with no apparent bruising or significant swelling.

  • Follow-up call scheduled in 2 days.

PILs & PICs (Specific to Cosmetic Dermal Fillers)

  • Patient Information Leaflets (PILs)

  • Patient Implant Cards (PICs)

  • From 1 December 2021, implantable and Active Implantable Medical Devices (AIMD) require patient information materials in the form of PILs and PICs, unless specifically excluded. (Therapeutic Goods Administration)

  • Completed by the practitioner and given to the patient after treatment.

  • Purpose: to ensure the patient is aware of the details of the product implanted and better traceability of the product in order to more quickly and effectively alert patients and health practitioners to safety issues such as precautions or recalls.

Consent Forms

  • Written consent is an integral part of the informed consent process.

  • Read through the consent form with the patient, highlighting expected side effects and potential complications.

  • The consent form should be:

    • Clear

    • Concise

    • Concrete

    • Correct

    • Coherent

    • Complete

    • Courteous

Patient Photos

  • Pre and post photos

  • Dermatoscopy photos

  • Skin analysis photos

  • Complications

Prescriptions

  • Required for any scheduled medication, e.g., neurotoxin and dermal filler.

  • Doctor requires patient’s medical history.

  • Doctor must consult directly with the patient either face-to-face or via telemedicine.

  • Doctor confirms indications, approves the treatment plan, and signs the prescription.

  • Nurse documents the above in progress notes or consultation notes.

  • Must be contemporaneous. Has to happen wihthin a reasonable tiem frame relating to the procedure

Patient Documentation and the Law

  • Any organisation providing healthcare should adhere to the National Safety and Quality of Health Service Standards (NSQHS).

  • The NSQHS criterion for patient documentation states it should be:

    • Relevant

    • Accurate

    • Complete

    • Up-to-date

Patient Documentation and the Law – Cont.

  • For documentation to support the delivery of safe, high-quality care, it should:

    • Be clear, legible, concise, contemporaneous, progressive, and accurate.

    • Include information about assessments, actions taken, outcomes, reassessment processes (if necessary), risks, complications, and changes.

    • Meet all necessary medicolegal requirements for documentation - Australian Commission on Safety and Quality in Health Care.

Patient Records and the Law

  • Must be kept for a minimum of 7 years (from the last entry date).

  • Destroy medical records securely.

  • Keep a register of destroyed records (NSW, VIC & ACT).

  • Store medical records securely to protect patient privacy, e.g., protect records from unauthorised access, damage, theft, hacking, etc.

Adding to Notes at a Later Date

  • Notes should be contemporaneous.

  • Information may be missed at the time or realized later.

  • You can add to your notes, but date/time stamping it shows you acknowledge the notes were inadequate.

  • Don’t attempt to add notes so they appear contemporaneous, as this may have legal implications.

Written Documentation in the AACDS Student Clinic

  • NPQ

  • Consultation guides

  • Consent forms

  • Pre & post-treatment information

  • Case study templates (consultation and progress notes)

  • Face chart (injectables only)

  • Patient feedback forms (completed by patients)

Importance of Patient Photography

  • Medicolegal issues

  • Monitoring patient progress and results

  • Marketing purposes

  • Education purposes

Obtain Written Consent

  • Must gain consent in writing before taking photos.

  • Consent may be a separate consent form or part of the NPQ.

Patient Photos and Marketing

  • Can you use before and after photos for marketing purposes?

    • Yes, but make sure:

      • Photos and accompanying information are not misleading or deceptive.

      • The patient has consented to using their photo for marketing purposes (be specific how, when, and where photos will be used).

      • They do not make references to cosmetic injectables or any S4 medications.

Example of Misleading or Deceptive Marketing

  • Retouched / photoshopped images

  • Makeup application

  • Using lighting to create shadowing and/or different angles

  • Different models before and after!

Misleading Marketing: Wrinkle Relaxer

  • Images directly reference a wrinkle relaxer (S4 medication);

  • This is in breach of the new TGA advertising guidelines.

Information Accompanying the Photo(s)

  • Australian Competition and Consumer Commission (ACCC) protects consumers against false or misleading advertising claims.

  • ACCC takes court action against traders making false claims about products, profiting from vulnerable people's desire to change appearance or improve wellbeing.

  • If something sounds too good to be true, it usually is.

ACCC Case Study

  • The ACCC sought permanent injunctions against DanozDirect to prevent them from representing the Abtronic (a muscle-stimulating device).

  • This was due to terminology like:

    • “it can flatten your stomach 'once and for all'”

    • “your 'love handles' disappear and your thighs and bottom firm up—with no sweating involved”

    • “you can get the results of up to 600 sit-ups in just 10 minutes without any effort"

Example of Correct Marketing

  • Same background

  • Same angle

  • Same position

  • Same lighting

  • Same camera

  • Correct information

  • Patient is also de-identified

Capturing Correct Photos

  • Clear (is your camera taking clear photos?)

  • Resolution (does your camera take photos at a high resolution?)

  • Consistent (lighting, camera, positioning, distance, background)

  • Prepare the patient (remove makeup, use a headband or bouffant cap to remove hair from face)

  • Consider clothing (is it in the way of the proposed treatment site?)

Photography Set-Up

  • Basic

  • Advanced

Other Modalities: Skin Analysis Devices

  • Excellent tool to take quality images for dermal therapies (surface textural irregularities, vascular and pigmentation, hydration, porphyrins, and sebaceous activity).

  • Some examples include:

    • VISIA

    • Clairderm

    • OBSERV

    • Scan-X

    • SpectrumOne

Protecting Your IP/Photos

  • Photos in which the patient has consented for you to use for marketing purposes can be considered your intellectual property.

  • Photos can be stolen from websites and/or social media.

  • Often stolen from by a foreign clinic.

  • Protect your IP by watermarking the photo.

  • Not bulletproof but will deter!

Positioning and Orientation

  • Each type of cosmetic procedure will have a set of positions most suitable for capturing pre and post photos.

  • Also applies to cosmetic surgical procedures.

  • You will need to know these positions in your role as a dermal therapist or cosmetic nurse.

  • See ’Photographic Standards in Plastic Surgery’

The 5 Standard Positions for Dermal Therapies on the Face

Frontal

Left Lateral

Right lateral

Right oblique

Left obliqeue

Camera Distance to Patient

  • Be Aware of Camera Distance to Patient

  • taking the photo approx 40 cm form the patient can avoid distortion

Taking Photos of Intimate Areas

  • Yes, you can

  • Not all clinics do

  • Attempt to protect patient modesty if possible

  • Leave underwear on

  • Patient may feel more comfortable if the photo is taken on the treatment bed

Clinical Photography Apps

  • Considerations:

    • In what country is the server that stores the images/information?

    • If not in Australia, does this breach APP 8?

    • What if the company/app no longer exists?

    • What if you fail to pay your monthly/annual subscription?

Patient Photography Apps

  • “There are smartphone apps that are specifically designed for capturing and managing clinical photos. Caution is advised in using apps that have been downloaded from online stores for health information, as it is difficult to tell whether they are credible and secure. It might not be possible to control the use or disclosure of a photo shared via an app. It is wise for users to review the app’s privacy policy and the app’s compliance with cross-border disclosure requirements”. - Royal Australian College of General Practitioners

Summary

  • Written and photographic documentation are part and parcel of providing a safe health service, running a successful clinic, and minimizing medicolegal issues.

  • You must always consider the laws surrounding written and photo documentation.

  • Further consideration is required when using photos for marketing purposes.

  • Standardize your photography.