Med spa patient records, on one screen

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:

• Presenting complaint and history
• Examination and assessment
• Plan
• Confirmation that consent was discussed

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. Reception 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.

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.