On a sliding scale of 1-10, how important would you say keeping your client records up to date is? Six? Eight? Nine? It’s up for debate… but we’d say they’re right up there.
In fact, we’d go as far as to say they’re one of the most important things you do as a healthcare professional. So today, we’re here to state the importance of keeping treatment records.
It might sometimes feel like they’re just another piece of admin to be ticked off the list, but records play a vital role in the health of your business, your reputation as a professional, and client safety. They can help you elevate the experience of your customers while also acting as the first line of defence if you ever receive a complaint or require a compliance audit.
Not convinced? Our guide to keeping client records up to date will help you.
Are you struggling to keep up with client information and communication? Say goodbye to the hassle of manual record-keeping and hello to efficient communication, streamlined scheduling, and enhanced compliance. Discover Pabau’s built in Electronic Medical Record feature.
What is a client record?
When we talk about client records we often think about notes. However, a client record isn’t just a treatment note. It could be a photo. A chart. An email communication to the client or an SMS. All of these components work together to create a detailed picture of the patient.
The purpose of client records
The importance of completing client records correctly shouldn’t be played down.
Keeping up-to-date client records isn’t a task that’s been invented just to make your life harder. Really! In fact, when you use client records properly they should make your life simpler. With detailed patient notes in place, you’re prepared for every eventuality.
A client record serves various purposes, such as:
- To keep track of client treatments
- For patient management purposes
- So you’re aware of allergies or medical conditions
- To create a bank of evidence for insurance purposes
- To empower other practitioners to treat the client
- Helps to build rapport with the client
- So you can market your services properly
Let’s unpack these in a bit more detail…
Why stay on track with client records?
Keeping the information you hold on your clients safe, secure and updated is important. Here’s why you should be keeping your client records up to date, whatever services you provide to them and wherever you provide them:
To keep track of client treatments
This is one of the most important reasons to keep client records up to date. It provides a clear record of products or treatments that a client has had to help you track progress and replicate the same service in the future. It also helps you to stay sure of what works best for your clients, so that you can provide the best customer care and service for them.
Knowledge is power, right? If you know what works best for your clients you’re in a much better position to provide the best customer care and service for them. Otherwise, a customer can walk in the door and ask for ‘the same as last time’ and you have no idea what that is.
2. For patient management purposes
Do you know which of your clients have filled in consent forms and which ones haven’t? Are you always 100% sure that every client you’re seeing has completed a medical questionnaire? The only way to know for certain is to keep your forms on your client record.
It’s the only way to know – at a glance – if your client has signed their intake form, updated their medical questionnaire, or completed a patch test for the service. Having all your forms stored as part of the client record is key for effective client management.
Awareness of allergies or medical conditions
Some clients forget to mention allergies or medical conditions unless they’re prompted. The last thing you want to do is prescribe or treat them with something that they’re allergic to. That’s why it’s so important to be hyper-vigilant when it comes to keeping client records up-to-date.
You can flag contraindications, know which treatments should be avoided, and make sure that colleagues are aware of allergies or reactions if they’re ever treating the same clients.
For insurance purposes
Many insurance providers insist on consultations and accurate record-keeping. They’re one of the first things that you can fall back on in the event of needing to claim on your policy, especially if it’s a client that’s raised a claim or legal proceedings against you.
Rather than relying on memory, your records will confirm your account of the facts. Plus, if you don’t have accurate records, your policy could be void anyway. It’s always best to be aware of terms and conditions like this in your insurance before you need to know and it’s too late.
5. To create a scalable business
When you first start out with your business you probably treat all your clients yourself. However, this isn’t particularly scalable. Keeping comprehensive client records will enable you to create a system that empowers any qualified practitioner in your business to treat any client.
The practitioner simply has to log into the patient record to access previous treatments and medical history. Meanwhile, it also benefits the client. They can book in with anyone in the practice and know that they’re going to have a cohesive, consistent experience.
6. To build rapport with the client
Some of your clients may only visit the practice every few months or so. Unless you have a fantastic memory, you’re never going to remember what you chatted about at the last appointment. Right? And that can make building that personal relationship harder.
This is where your client records can come in and do the heavy lifting for you. They can act as a mine of information that you can use to create that personal relationship with your client. Store notes with personal anecdotes, conversation details, or anything else you wish.
Marketing your services
Which of your clients do you have consent to market to? Keeping your records up to date means that your marketing is compliant with marketing legal requirements like GDPR, but it also means that you know when you contact your clients about offers and services.
You can check a box on your client records so you know who you should (and shouldn’t) be contacted based on their preferences. Being able to let your clients know about your special offers, loyalty schemes and discounts can help you boost your revenue.
What information should be in your client records?
The type of information that you collect will be specific to your business and services. In general you’ll want to collect the following information as a minimum:
- Full name of client
- Contact information
- Date of consultation
- Details of lifestyle and medical history where these are relevant to the therapy you give
- Brief description of the therapy or treatment given
- Unusual reactions to the therapy or treatment given
- Details of patch tests carried out, if applicable
- Any contraindications
- Advice or recommendations you give
- Relevant comments made by the client about the therapy you provide
- Treatment records (such as colours used or treatments administered)
- Details of aftercare advice
- Any consent forms should be kept with the record
- Get your client to sign the form
All of this information won’t need to be updated every time a client visits you, but it is good practice to keep your information up to date. Especially the essential information, and the information that you’ll need in case anything goes wrong.
Consequences of poor record-keeping
Poor record-keeping can have really dire consequences. This abstract, written for the British Journal of Nursing, highlights some of the failures of poor record keeping.
While these examples are in the context of a hospital and lie on the more extreme side of the scale, they’re all things that have actually happened – patients having operations that were intended for someone else or having organs removed that shouldn’t have been.
In the healthcare sector, being lax with record-keeping also carries risks…
- Prescribing a drug a client has an allergy to
- Not knowing what treatment the client had last time
- Not being equipped to deal with customer complaints
- Not having documentation for compliance audits
- Creating a less personal experience for the client
You may also find yourself administrating a treatment when circumstances have changed – i.e. due to pregnancy or when a client has been prescribed medication elsewhere that you weren’t aware of. It’s not worth the risk, which is why you need a proper system in place.
Client treatment records - FAQs
How often should you update client records?
Once a week, once a month, every six months? No, you should update your client records every time the client comes in for treatment. A good practice management software can help you with this – it’s the only way you make sure your records are up-to-date.
How should client records be maintained?
There are various ways to maintain your records, but some are better than others.
Some practitioners start with pen and paper, but then quickly realise that it’s pretty limiting. No one really wants to have to rifle through dusty filing cabinets in 2023, do they? Not to mention the fact that you have to be on-site to be able to access them. Like we said: limiting.
The best choice is practice management software, which we’ll get to in a bit.
How long should you keep your client records?
How long you store client records depends on the type of practice and the location.
UK law states that medical records created by the NHS should be kept for 12 years – and this also applies to private healthcare providers. GP records are kept for 10 years after the last treatment in England and Wales, and three years in Scotland.
Meanwhile, in the US it’s slightly different. HIPAA doesn’t state how long client records should be kept for and so, instead, it’s decided on a state-by-state basis.
So how long should you really keep client records then?
Ideally, as long as possible. It’s possible for a claim to be raised up to three years from the time a client became aware of a problem. If you get rid of your records after 12 months, you could be left out in the cold if you need proof of your actions.
There are some exceptions to this time scale. Patients who are under 18 or people who don’t have full mental capacity sit outside of this general rule, so with these types of records you need to keep them indefinitely.
Record keeping by industry
We’ve covered the importance of completing treatment records in general terms. Now, let’s break it down by industry. Of course, there will be some crossover in how different sectors use client records, but there are some specifics that are more important to some than others.
Aesthetics / med spas
Aesthetics practitioners and med spas will really benefit from the visual information stored in the client record, as well as the notes. Features like charts and before and after photos are crucial.
Being able to plot injection points is essential for aesthetics practitioners and med spas. Having a face mapping tool in place enables practitioners to accurately plot where a client has been injected, which product has been used, and how many units have been used.
- Before and after photos
Before and after photos are critical. If you have photographs on the client card then not only can you review the effectiveness of past treatments and share the photos with the client, you can also ask for permission to share them online as part of your marketing strategy.
- To flag up allergies and contraindications
One example of this is a Hydra facial. One of the steps in the treatment contains a shellfish extract, so clients who have an allergy shouldn’t have the treatment. However, you’re only going to know that if you have allergies and contraindications flagged on the system.
Having a robust client record system is critical for private practices and other healthcare businesses due to the nature of the patient information they need to collect.
- To keep medical records up to date
Medical practitioners need to make sure that all medical questionnaires and forms are up to date. If you build that into your process – so that clients always review and update their medical records before their appointment – you can be sure everything is correct.
- To evidence instructions
Pre-care and aftercare is crucial for medical treatments, especially if we’re talking about things like cosmetic surgery or hair transplants. If a client doesn’t follow these correctly, they may not get the results they want. Documenting this in the client record is therefore critical.
- To flag up allergies and contraindications
A robust client record system is essential for flagging any medical conditions, allergies, or contraindications. You need to be 100% confident that any vital medical information is stored and mapped against prescriptions using the BNF database and SNOMED codes.
Why are client records important for hair salons? A hair salon may not be gathering as in-depth medical information as other industries but allergies and personal preferences are critical.
- To have a record of prior treatments
Every hair salon customer is going to have a particular way preference for how they like their hair done. A client record is the perfect place to store this information. Note down hair colour formula details, allergies, or even specific details on how the client likes their hair cut.
- To build a rapport with the client
Add notes about any notable conversational topics from last time. You can even add details on how they take their coffee or even note if they have a preference for a “quiet chair” for the service – a chair marked out for introverts who don’t want to have to make small talk.
- It can create upselling opportunities
If you have a note on your client card that says this client tends to purchase products used as part of the service, you want to know about it. By highlighting this in the treatment notes it can direct the stylist to recommend products and boost the overall spend of the client!
Why is it important to keep client records in beauty? There are many reasons why detailed client records are important for a beauty salon. Here are three for starters:
- It sets your team up for success
Not every client will book in for the same member of staff each time. If a client comes in and asks for the colour treatment they had previously and you don’t have notes, you’re stuck. Detailed notes equip your staff members with the information they need to do the job.
- You can build stronger relationships
A lot of the experience of visiting a beauty salon is the interaction between the client and the customer. If you have notes about the client, such as a note to ask about the trip they were getting their nails done for before, you’re much more able to build a rapport.
- For marketing purposes
Before and after photos are another really important detail to have stored on your client card, especially when it comes to treatments like brows, lashes, lash extensions. Sharing social proof on your website (with consent, of course) is a sure-fire way to encourage more bookings.
The importance of keeping records in counselling probably doesn’t even need to be explained. Use them to document your assessment, diagnosis, and any actions you take.
- Assessment and diagnosis
Client records are used to gather and document information about the client’s background, presenting issues, and mental health history. This all helps the counselor make an accurate assessment and diagnosis, which is essential for developing an effective treatment plan.
- Treatment planning and progress
Counselors use client records to document the client’s progress. This includes recording session notes, insights, goals achieved, and challenges faced. It helps both the counselor and the client track their journey and evaluate the effectiveness of the treatment.
- Communication with other professionals
As a counsellor or therapist, you may communicate with other healthcare professionals regarding their treatment. You might refer them to another treatment center or support group or get in touch with their GP or psychiatrist. This should all be noted in the record.
Record-keeping without the right tools
It’s not easy starting up your own med spa or healthcare business.
And it’s often difficult to know what sort of challenges you’ll experience when you don’t have the right tool for client records… until you actually experience those challenges.
But as a rule, when the administrative side of the business starts to take up too much time and impacts your overall efficiency, you feel like you’re not delivering a good customer experience, and you’re not able to grow, that’s when you know it’s time for a change.
Here are some of the challenges experienced by our customers…
Copy + paste processes
Amish Patel, who owns Intrigue Cosmetic Clinic in Kent, didn’t have a proper system in place for client records at first. He was connecting his paper patient records to digital photos of the patient. This meant copying and pasting photos into a PDF file and then having to create a whole new PDF record every time the client came in for an appointment – not exactly efficient.
“When I was seeing repeat patients, I was having to go back and find those paper records and link it to a record on the computer where I had the before and after images.”
Amish Patel, Intrigue Cosmetic Clinic
Systems that can’t scale
Another practitioner, Dr Ahmed El Houssieny, describes how using pen and paper client records became very challenging when he started splitting his time across two different practices. Unless he knew which client was attending where on what day, it was impossible.
“Whenever a patient had a follow-up appointment, you’d had to fish for the notes, make sure they were there, update them, and then store them again. It wasn’t an easy process.”
Dr Ahmed Houssieny, Bank MediSpa
How to store client information safely
Paper records just aren’t cutting it any more. They’re time consuming, take up a ton of storage space, impact on the environment and they aren’t secure. Plus they can be lost, damaged or get into the wrong hands far too easily.
You have a responsibility to protect the data of your clients, and paper records can leave you in the lurch (and open to a huge fine).
You also need to protect yourself as a professional, which is where paper records can let you down if they’re lost or damaged.
Even destroying paper records is stressful as you have to make sure it’s done whilst protecting confidential information and decide on the right time to do it – otherwise you can end up with a lot of paper to carry around with you.
What should you use for good record-keeping?
That’s a good question. There are loads of products targeted at people just starting out, such as downloadable client records on Etsy that you can edit. While these look aesthetically pleasing and may seem like a good choice for right now, we think you can go one better.
Using a digital client record system like this might seem one step ahead of using pen and paper, but they’re not much better. Frankly, a basic tool will do a basic job.
They won’t help you with before and after photos, charts, and automatically pulling through information from your medical questionnaires and intake forms. They also won’t build collecting patient data into your overall process, so you could simply forget to do it.
Enter stage left… practice management software.
Practice management software for client records
1. It’s safe and secure
With security features in place like two-factor authentication, you don’t need to worry about people getting access to confidential information accidentally.
2. Roles and permissions features
You can lock down patient records so that only staff with the right credentials can view patient information. You can even make them fully private so only you can view them.
3. It’s a space saver
The days of bulky filing cabinets are over. If you work from home or hire a space then you need a lean and clutter-free operation – digitizing your client records is the way forward.
4. You can access it from anywhere
Do you work from multiple locations or visit clients at home? Using a cloud-based practice management tool means you can access patient records whenever, wherever!
5. It saves you time
Forget all those manual steps that are needed to update a client record. With practice management software, you can automate tasks and save yourself hours each week.
10 powerful Pabau features for easy client record-keeping
1. Robust EHR (electronic health record)
For a client record to be truly useful, it needs to be comprehensive. In Pabau you can create incredibly detailed electronic health records for your clients with treatment notes, charts, before and after photos, previous (and upcoming) client communications, and lots more.
You can use all these different tools to build a really robust patient record.
2. Flagging contraindications
We mentioned earlier about the risks of not having patient allergies mapped to their record. One key safety measure Pabau has in place is that you’re not able to free-type allergies into the system – you have to choose from a list and store the SNOMED code in the client record.
We use the BNF drugs database for prescribing, which will flag any contraindications. What that means is that you’re not at risk of an allergy going unnoticed because it’s misspelt.
3. Date-stamped face-mapping
Are you an aesthetics practitioner? Use Pabau’s injecting plotting tool to accurately plot the injection points on a client’s photograph in the areas where they’ve had treatment. You can even add the batch information of the product you’re using and the expiration date.
Once you save this information it’ll all be stored as a treatment note in the client card in Pabau. Even better, it will be dated with that day’s date for 100% accurate record keeping.
💡 Pro tip
If you add your products into the inventory in Pabau then this will automatically deduct when you add in the number of units of the treatment you’ve administered.
4. Digital pre-care and aftercare instructions
Handing a client a paper leaflet after they’ve had their treatment with you isn’t ideal. For one, it’s bad for the environment, but secondly, there’s no evidence that they’ve received it. Right?
When you send a client these instructions by email there’s a digital record that it’s been sent and that digital record is stored on the client record on Pabau. You can even check if they open the email or not. It makes everything much easier when it comes to compliance audits.
5. Built-in digital signature tool
Not having a digital signature tool in your system makes things a whole lot harder. For one, it means that you can only get patients to sign forms in the clinic. If it’s busy on that particular day and your front-of-house team forgets, that can cause issues later on.
The only fool-proof way to do this is to have a digital signature tool built into the system. That way, clients can sign forms via your client portal in their own time. You’ll be notified when it’s completed so you’ll never run the risk of a client not having a signed form.
6. Patient journey on an iPad
Keeping your client records regularly updated is tricky. However, it’s much simpler if you build this into the patient journey so that every time a client comes to see you, they’re required to review and update their medical information. On Pabau, we call this the patient journey.
Every client has to review their medical questionnaire and consent forms on the iPad before their appointment. Any fields that they update will map to the client card on the system and automatically update each time – giving you accurate and up-to-date client records.
7. Client portal for self-service
Another way to make it even easier for you to update your client records is to put the power in the hands of your clients. In other words, enable them to update their own medical information via the client portal. Of course, if you prefer, you can toggle off this functionality.
Of course, if you prefer, you can toggle off this functionality if you’d prefer to be in control. But it’s definitely a feature to consider to help you maintain accurate records.
8. Before and after photos
Before and after photos are essential for completing client records correctly. Using Pabau, you can take photos using the iPad when a client arrives for their appointment. In fact, your front-of-house team will be prompted to do this as part of the five-step patient journey.
These photos automatically upload to the client record, which means that you never have to store photos on a personal device and blur those professional boundaries.
💡 Pro tip
You can choose from a selection of ways to present the photos. Put them in a timeline to track the client’s progress and share them with the client directly via a unique link.
Updating client records? Completed it
Managing your records with specialist software, like Pabau, is a much easier way to manage your client records and keep their info safe and secure. You’ll save time, space and effort compared to keeping those records up to date manually.
Book a demo today to find out how Pabau can power your business.