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Templates, Clinical notes, Aesthetics

Aesthetics procedure note template

A aesthetics procedure note template that sets out what belongs in each section, ready to adapt to your own clinic. Below it is the same note filled in by the wai scribe from an invented consultation, line by line, for the clinician to read and sign.

Updated . Written by our clinical team, generic by design, with no dosing advice.

01Procedure note

TemplateAesthetics

Patient
[Name]
Date of birth
[Date]
Record number
[Number]
Clinician
[Name, registration number]
Consultation
[Date and time], [in person or video]

Aesthetics procedure note, botulinum toxin treatment

1Indication

  • The areas to be treated and the patient's goal.

2Consent

  • Risks, benefits, alternatives and the expected result discussed, with a cooling-off period where it applies.
  • Written consent and photographs on the record.

3Procedure

  • The product, its batch number and expiry, as recorded in the product log.
  • The sites treated and the amount at each site, recorded in the treatment chart.

4Findings

  • What was found or measured, in terms another clinician could act on.

5Complications

  • Any complication, or a record that there were none.
  • Anything that did not go to plan, and what was done about it.

6Aftercare and follow-up

  • Aftercare advice given in writing.
  • Review appointment arranged.

Draft

[Clinician name]

[Role], [registration number]

Signed [date], [time]

How the wai scribe fills it

The same note, written from an invented consultation.

Each line links to the moment in the transcript it came from, and the clinician reads, corrects and signs the note before it is filed.

01Procedure note

SignedAI-assisted, edited by the clinician

Patient
Invented patient, for illustration
Clinician
[Clinician name]
Consultation
In person

Aesthetics procedure note

1Indication

  • Forehead lines, as assessed. Patient's goal is softening.00:40

2Consent

Completed by the clinician from the record.

3Procedure

  • Product, batch and expiry recorded in the product log. Sites and amounts recorded in the treatment chart.02:50

4Findings

  • Mild erythema at injection sites, as expected.07:00

5Complications

Completed by the clinician from the record.

6Aftercare and follow-up

  • Written aftercare given. Review in two weeks.07:40

Signed and filed

[Clinician name]

[Role], [registration number]

Signed [date], [time]

Questions

What goes in an aesthetics procedure note?

Indication, Consent, Procedure, Findings, Complications and Aftercare and follow-up. Each section on this page lists what belongs in it, written for aesthetics.

Is the worked example a real patient?

No. The consultation is invented for this page, and no real patient or record is used.

Does the scribe sign the note?

No. The scribe drafts the note from the consultation, and the clinician reads, corrects and signs it, with the time and the change from the draft kept on the record.

Can we use our own note structure?

Yes. Your clinic's own sections are set up once, and the scribe writes each consultation into them.

Come back to the note, written and ready to sign.

See the wai scribe write an aesthetics procedure note on your own structure, in a 15 minute video call.