Keys to Keeping Medical Records in a Medical Spa

Posted By Kate Harper, Monday, October 8, 2018

Medical records


By Patrick O'Brien, Legal Coordinator for the American Med Spa Association

Medical spa medical records are a piece of your compliance plan that cannot be overlooked. It's easy to look past them when considering other parts of building your business, but they are vital to your practice. According to our 2017 State of the Industry Report med spas indicated that 70% of their clients are repeat customers. This is a wonderful statistic to read because loyal customers are happy/satisfied customers and they can and will generate great recommendations and buzz for new customers. But these loyal clients and customers are much more than that; they are also patients. Because most of the procedures offered in med spas are medical procedures the practice must retain appropriate records just as any other clinic or doctor's office would.

The content and retention requirements for medical records are set by each state and their respective medical boards. In general the records should include, among other things, medical histories, exam notes, details of procedures and treatments. Typically these should be kept for several years after seeing the patient with the two years that New Mexico requires being the shorter side and 10 years as in Tennessee and South Carolina being on the longer side. Physicians may be subject to Board discipline for failing to properly maintain and keep patient records, so you will want to review your own state statutes and advice of your medical board to determine what information should be kept in the medical records and how long you should keep them.

Watch AmSpa's webinar on patient charting for more information on the topic.

The 2017 industry survey also uncovered this interesting stat: half of med spas we heard from see more than 50 patients a week. This is great from a business perspective, but daunting from a record keeping perspective. Every one of those visits will need an entry made in that patient's records, and the med spa's records system, in addition to being able to keep up with the volume of updates, will also need to comply with Federal and State privacy laws.

The big one is the federal Health Insurance Portability and Accountability Act (HIPAA). I'm sure you'e heard more about HIPAA than you ever cared to so I won't bore you with too much detail other than to say patient medical information needs to be securely stored and accessible only to authorized individuals. Most states also have a version of a patient information privacy law with similar concepts.

While the general gist of the laws are "protect patient information" you'll need to check your jurisdiction for specific implementation requirements. For instance California has the Confidentiality of Medical Information Act which has stricter requirements on when and who you can disclose confidential health information. AmSpa members can check their state's medical aesthetic legal summary, or utilize their annual 15-20 minute complimentary compliance call with ByrdAdatto for more specific information.

It takes a lot to build a successful med spa and the more successful it becomes the more important it is to have a streamlined and secure medical record system and policy. Don't let paperwork be a limitation on your Spa's success. If you want to learn more about record retention policies and systems consider attending one of AmSpa's Medical Spa & Aesthetic Boot Camps to learn medical spa legal and business best-practices.

If you liked reading through our 2017 State of the Industry Report we will be gathering data for 2019 survey soon. Did your spa see more customers this year? Did you add new service lines? Or bring on more staff? We hope to hear from you so together we can define data in the medical spa industry.

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