In this section, I explain why it’s vital to keep all client records including patch test results. I’ve also included sample forms that you can adapt and use with your own clients.

You should maintain and update client records for several reasons:

  • To track the client’s progression.
  • To record the products used and timings so you can use these at further visits and adjust the treatment plan if required.
  • Tracks any aftercare you provide the client.
  • Records patch test history.
  • As a backup in case, the client has an adverse reaction to treatment.
  • For legal reasons if the client brings a claim against you.

Records also provide contact details in case you need to alter or cancel an upcoming appointment.

Client records can be stored electronically or filed away manually and should be updated at every visit. If consultation forms aren’t updated and don’t contain a history of services and dates, this may invalidate your insurance.

Forms should be kept for the timeframe suggested by your insurance company. This may be for up to six years.  If a client is under 21 at the time of service, then it is recommended to keep the forms for six years past their 21st birthday.

Client confidentiality must be always protected. Forms need to be locked away in a secure cabinet, and electronic records should be held on a password-protected computer.

All information must be accurate and necessary for the service or treatment being performed.

Individual client records must be available for the clients to view if requested.

Data should not be passed on or sold without the client’s prior written permission.

The following details should be recorded on the client consultation form:

  • Personal details – name, address, contact details
  • Results of any patch tests
  • Contraindications
  • Contra-actions
  • Reasons for the treatment
  • Any reactions to treatments/previous treatments
  • Home care advice/suggested retail items
  • Any sales
  • Treatment timings/products used etc.
  • Next appointment or recommendations

Any contraindications and possible contra-actions should be identified and discussed before the treatment. In the case of a medical referral, you should keep a copy of the GP’s letter with the client’s record card.

Consultation forms must be signed and dated to prove that you have covered everything and given the correct advice and treatment plan.

Your insurer will require you to document and keep a record of all treatments performed on your client. This will help protect you in the event of an issue arising

You should keep a record of the pre-drawing and document the procedure with before, during and after photographs. These will act as a reference should the client have any complaints or questions after the procedure.

I recommend Gettimely, which has a client record system on an app called “Consult”. It’s great for uploading photos straight to your client’s records on your database.