6 forms you must include in your body contouring client record

Operating a body contouring business requires you to collect and record certain health information from your clients, and to document their treatments and the other care you provide, pretty much like what’s done in a doctor’s office.  And though you may not be running a medical practice, you should abide by the same standards and follow the same rules regarding documentation of care and protection of health privacy.  At a minimum, your body contouring client record, whether it’s paper or electronic, must include these six forms.

1. Medical and Personal History form
2. General Consent form
3. HIPAA Privacy Notice form
4. Progress Notes form
5. Treatment forms
6. Consent forms

 

In this article you’ll learn these things

• Your body contouring client records should tell your client’s stories
• What is Intake Paperwork?
• What Intake forms do you need?

Medical and Personal History form

General Consent form  FREE DOWNLOAD!

HIPAA Privacy Notice form

• What are Continuity of Care forms?

Progress Notes form

• General Documentation Guidelines checklist
• Treatment forms – essential elements checklist
• Consent forms – must-have statements

 

Introduction:  Your body contouring client record should ‘tell your client’s story’

You are a body contouring provider because you love helping people. And proper data collection and documentation helps your clients.  A proper body contouring client record tells your client’s full story – who she is, why she came in, what her goals are, what the plan of care is, what has she done so far, how it’s been going…information critical to ensuring a high quality of care, good results, and a satisfied client.

 

Intake Paperwork

Intake Paperwork is comprised of the information and forms you should gather from your client before you deliver any care.  Intake paperwork for the body contouring client includes these three forms:

1. Medical and Personal History form
2. General Consent form
3. HIPAA Privacy Notices form

 

1. Medical and Personal History form

Your client chart should include the client’s demographic and identification information as well as the client’s medical history.  These two types of information are easy to combine into one single form, the Medical and Personal History form.

 

First, identification information is the information that helps identify the client, such as name, date of birth, etc.  We recommend you also collect contact information, such as email, phone number and address.  And asking the client for her referral source within this section provides essential marketing data for your business.

 

Second, medical history information includes allergies, past treatments, current and past diagnoses, current medications, and medical & surgical history.

 

Finally, your client must sign and date the form.

 

But it’s not a form to be done only initially or annually, it’s critical to update the medical history information at each visit.

 

Want to learn how to conduct the perfect medical history… plus get a FREE downloadable Medical and Personal History form?  Click here!

 

2. General Consent form

Your Intake Paperwork should include a General Consent form that delineates the office procedures, policies, and actions you will take in delivering your client’s care.

 

We recommend to include the following items (and any other items you feel are appropriate for your body contouring business) in your General Consent form.

• Explanation of how you establish care
• Your client’s agreement to disclose her complete medical information
• Your assurance of confidentiality of the client’s information
• Client’s consent to photography/measurements
• Client’s consent to email, text, phone communication from your business
• Basic product information
• Explanation that her consents continue unless withdrawn

 

Need a General Consent form for your body contouring client record?

Complete the form below to get your FREE Consent Form.

 

 

 

3. HIPAA Privacy Notices form

HIPAA, acronym for the Health Insurance Portability and Accountability Act, requires health care providers to protect the privacy of their patient’s health information.

There are numerous requirements under the law, but our focus in this article is on the requirement for you, the body contouring provider, to provide written notice of the Act’s privacy protections.  You meet this notice requirement when you provide your client with the HIPAA Privacy Notices form, and she reads it and signs it.

 

The Act requires the language in the form to meet very specific elements.  You can find Model HIPAA Privacy Notice forms to use in your body contouring business on the HHS website.

 

Continuity of Care forms 

Continuity of Care forms connect the dots between the other forms. Without looking at any other form, the Progress Notes form should provide a brief, not detailed, chronological recital of the client’s care.  Details are not needed in the form because the details of the client’s care are contained in the other forms within the body contouring client record.

 

4. Progress Notes form

The Progress Notes form should be a simple form with lines for dated notes.  The Progress Notes should be a chronological snapshot of what has transpired with the client.

 

General Documentation Guidelines

• Handwritten notes must be clear and readable
• Do not squeeze in words or comments
• Draw a horizontal line to the end of the line at the end of finished notes
• Always enter the date of each entry
• Always sign each entry and if you’re signature is not legible, print your name beside your signature
• Never add to a previous entry.  Instead, add a late entry by writing the current date, and writing “late entry”
• Do not use abbreviations unless they are standard medical abbreviations
• Use only a blue or black ink pen.  Do not use pencil or any other color of ink
• Strikethrough errors with a single line, then initial.  Do not use whiteout or completely blackout the note

 

5. Treatment forms

You should document each treatment you perform on a Treatment form customized to capture all of the appropriate details for the particular technology and/or machine.  In other words, you should use a different Treatment form for Vacuum Therapy treatments than you do for Electromagnetic Muscle Stimulation (EMS) treatments, and so on.

 

Treatment Form Elements for the body contouring client record

Essential

• Client Name
• Date of Service
• Main concern
• Protocol Name
• Area Treated
• Treatment Number
• Treatment Time
• Committed to a series?
• Return appointment
• Home care
• Comments
• Technician Signature

Technology or machine dependent

• Mode
• Energy Level
• Suction time
• Release time
• Post treatment massage
• Setting
• Intensity
• Etc

6. Treatment Consent forms

A signed written consent form provides proof that you gave your client the information about the risks and benefits of the treatment she is undergoing…and that she has agreed to move forward with the treatment.  It’s an essential component of your body contouring client record and you should not perform a treatment without first obtaining it.

 

Consent Form Checklist

___What the treatment is used for

___Risks and discomforts

___Benefits

___A statement that there are alternatives to undergoing treatment

___A statement that she has read and understands the form

___The client’s signature

___The date it was signed

___A legible witness signature

 

Do your body contouring client records contain these forms and meet these elements?  If not, use the information, checklists and forms provided in the article to make your body contouring client records complete.

If you’d like to learn more about body contouring client records in the body contouring business, visit www.bodycontouringacademy.