Face map and face chart template for aesthetics clinics

The template

[Clinic name] face map and treatment chart

Form version: [date]

This chart records assessment and treatment. It does not provide an injection plan or establish suitability for treatment.

Patient and visit

Patient name: ___________________________

Date of birth / patient record reference: ___________________________

Appointment date and time: ___________________________

Practitioner name and professional registration, where applicable: ___________________________

Treatment performed / areas treated: ___________________________

Linked medical history and review date: ___________________________

Consent form title, version and date: ___________________________

Prescriber and prescription reference, where applicable: ___________________________

Diagram or photograph reference

Attach the clinic-approved blank front-view chart and, where needed, side views. Alternatively, reference a securely held clinical photograph used for recording. Identify each attachment below.

Front view reference: ___________________________

Patient’s left profile reference: ___________________________

Patient’s right profile reference: ___________________________

Other view / close-up reference: ___________________________

Diagram key: numbers identify treatment entries; letters identify baseline findings. Explain any other symbols used: ___________________________

Baseline findings and patient priorities

Patient’s stated concerns and intended outcome: ___________________________

Relevant assessment findings, including any pre-existing asymmetry: ___________________________

Previous treatment or findings in the area, with source and date if known: ___________________________

Assessment on movement, where relevant to the procedure: ___________________________

Plan reference and any changes agreed before treatment: ___________________________

Treatment-point record

Number each mark on the diagram and use the same number in this table. Complete only the fields relevant to the procedure. Continue on a labelled additional sheet if needed.

Preparation / dilution details, where applicable, with linked prescription: ___________________________

Total amount used and unit: ___________________________

Unused amount and disposal record reference, where applicable: ___________________________

Zone-based treatment record

For a procedure recorded by zone rather than point, identify the area on the chart and document the settings actually used. This table does not recommend settings.

Outcome and follow-up

Immediate observations, any unexpected event and action recorded: ___________________________

Linked incident or referral record, if applicable: ___________________________

Aftercare document title, version and delivery record: ___________________________

Clinic contact information supplied: ___________________________

Review date or agreed follow-up: ___________________________

Practitioner record

Completed by: ___________________________

Signature / authenticated record entry: ___________________________

Date and time: ___________________________

Later correction or addition, with author, time and reason: ___________________________