Clinical records
Each practitioner sees their day, then opens a visit with the patient's form, medical summary, consultation note and treatments given together. Sign it, and it's final.
Sana K. · P-00042 · 34
Sign and completeCheck before treating: takes blood thinners (from today's medical form)
Medical summary
Allergies: none known
Fitzpatrick skin type: III
✓ Reviewed today by Dr. Amna
Consultation note
Complaint · History · Examination · Assessment · Plan
✓ Consent discussed
Clinical notes tend to end up wherever there was space: paper, a spreadsheet, the booking app's comment box.
A returning patient's last treatment, dose and reaction are in a paper file in a cabinet, or in a colleague's head.
A comment box in a booking app can be edited or deleted later by anyone with a login. That isn't a record you can stand behind.
Front desk staff, managers and practitioners share one login level, so medical details are visible to people who don't need them.
How it works
Built for aesthetic and skin clinics, and usable by any practice that sees patients one-to-one.
Each practitioner sees their own patients: who's waiting and for how long, who's with them, who's later today and who's been seen. First visits and missing forms are flagged.
The visit screen puts the patient's medical form for this visit, their medical summary, the consultation note and the treatments given on one page.
Record the consultation and exactly what was used, down to the batch number.
Signing the note completes the visit. From that moment the note is final, and corrections are added as dated amendments.
My day · Dr. Amna
Waiting
Ali R.
Laser, full legs · waiting 6 min
Form missingWith you
Sana K.
Anti-wrinkle injections · since 10:02
Later today
Hira A.
Consultation · 11:15
First visitSeen
Maria L.
Hydrafacial · signed 9:58
Every patient has a medical summary covering allergies, conditions, medication, Fitzpatrick skin type and notes. It carries over between visits, so nobody starts from scratch.
The first time, it's filled in from the patient's own medical form. At every later visit, the practitioner confirms it's still correct, and the record shows who reviewed it and when.
The consultation note follows the structure practitioners already use:
For each treatment given, the practitioner records the product, the batch or lot number, the expiry date, the quantity and unit (units, ml, syringes and so on), the areas treated, the technique and any notes.
That turns a product recall into a question with an answer. Read more about treatment records and lot number tracking.
When the practitioner signs the note, the visit is completed. A signed note is final: it can't be edited or deleted, by the app or directly in the database.
Corrections are added as dated amendments that show who wrote them, which is the medico-legal norm. Completing the visit also starts the patient's review request and rebooking reminder.
Every patient has a record page with their patient number, age, contact details and every visit, whether booked or walk-in, plus completed visits and spend.
Practitioners also see the medical summary, every consultation note and every treatment given, across all visits.
Only practitioners and admins can read medical forms, summaries, notes and treatments. Front desk staff and managers see bookings and whether a form was signed, nothing clinical.
This is enforced by the database itself, not by hiding buttons, so a front-desk login can't read a clinical note even by going around the app.
Every change to the clinical record is logged with who made it, when, and the previous version. Every time someone opens a patient's clinical record is logged too. Only admins can read the log, on its own activity log screen in the admin panel.
New: when a record is shared outside the clinic, the disclosure is logged against the patient, and an admin can export a patient's record when the patient asks for a copy.
Clinical notes and treatment records can't be deleted along with a booking or a patient. See how we approach security and privacy.
Velvet Lead doesn't make HIPAA compliance or certification claims. If your practice must operate under HIPAA, talk to our team before you store clinical records, including about Business Associate Agreements with the hosting providers.
Honest limits
Velvet Lead's clinical record covers consultation notes, medical summaries, consent and treatment records. It deliberately stops there.
FAQ
No. It covers consultation notes, medical summaries, consent and treatment records. There's no e-prescribing, labs, imaging, insurance billing, coding, telehealth, and nothing clinical appears on the patient's own page.
No. A signed note is final and can't be edited or deleted, by the app or in the database. Corrections are added as dated amendments showing who wrote them.
Only practitioners and admins. Front desk staff and managers see bookings and whether a form was signed, nothing clinical. The database enforces this.
Yes. Every change and every view of a patient's clinical record is logged with who and when. Only admins can read the log.
Yes. It's filled in from the patient's form the first time, carries over, and is confirmed as still correct at each visit with who reviewed it and when.
We don't make HIPAA compliance or certification claims. If your practice must operate under HIPAA, talk to our team before storing clinical records, including about Business Associate Agreements.
Book a 15-minute demo and open a visit, write a note and sign it on our demo clinic.