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Aesthetic Charting Checklist: What a Complete Injectable and Laser Chart Contains
A complete aesthetic chart records who was treated, by whom and when; the consent and history reviewed; exactly what was used (product, lot number, amount per area, or device and settings); where it went; how the patient was at the end; and what happens next. Pull one recent injectable or laser chart and check it against the 30 fields below. This is a documentation checklist only; it does not say what to inject or which settings to use.
Prepared by Prospyr · Reviewed October 28, 2026 · Free, no sign-up, runs in your browser
Aesthetic chart audit
Practice name: ____________________
0 of 30 items done (0%)
Every visit
0/9Fields that belong in the chart whatever the treatment.
On every page or screen of the record.
Rules on who can order and perform each treatment differ by state.
Full-face photos are one of the identifiers listed in the HIPAA de-identification rule, so store them with the record, not on personal phones.
45 CFR 164.514(b)(2)(i)(Q)
Injectables
0/8Neuromodulators, fillers and biostimulators.
Lets you find every patient who received a product if a manufacturer issues a recall.
Laser and energy-based devices
0/7Lasers, IPL, radiofrequency and similar devices.
Record what was used. This checklist does not suggest settings.
After the visit
0/6CMS Program Integrity Manual, ch. 3, §§3.3.2.4–3.3.2.5
Add an addendum rather than changing the original entry.
CMS Program Integrity Manual, ch. 3, §3.3.2.5
Chart completeness
0%
0 of 30 items done. 30 still open.
- Every visit0/9
- Injectables0/8
- Laser and energy-based devices0/7
- After the visit0/6
Documentation fields only, not clinical guidance. Progress is saved in the page address, not on a server. Bookmark it to come back.
Auditing charts against a list like this? See what an aesthetic EMR charts →
How to run a chart audit with this checklist
- Pick charts at random. Five injectable and five laser charts from the last month, from different providers.
- Check one chart at a time. Mark the sections that do not apply (laser fields for an injectable visit, for example) as not applicable, then check each field the chart has.
- Print the result for each chart and note the fields that are missing most often.
- Fix the template, not just the chart. A field that is missing across providers usually means the chart template does not ask for it.
Related templates
Mark injection sites on the face chart template, structure the visit note with the SOAP note template, and record skin type with the Fitzpatrick skin type quiz. For consent forms, see the consent templates.
Frequently asked questions
What should an injectable chart include?
Patient identifiers, date, the treating provider and credentials, history and medications reviewed, signed consent for the treatment, product name, lot number and expiration, reconstitution where relevant, amount per area in units or mL, injection sites on a diagram, anything wasted, how the patient was at the end of the visit, aftercare given and the follow-up plan.
What should a laser treatment chart include?
The same visit basics, plus the device and handpiece or wavelength, the settings used for each area as the device displays them, skin type recorded at the visit, any test spot and its result, treatment areas, the session number in a series, eye protection used, and the skin response at the end of the treatment.
Why record lot numbers for toxin and filler?
If a manufacturer recalls a lot, the lot number in each chart is how you find every patient who received it. It also answers questions about a specific vial or syringe later.
How should I correct a chart after it is signed?
Add an addendum that is clearly marked as a later entry, with the date and the name of the person adding it, rather than changing the original. CMS guidance for medical review says the date and author of any amendment, correction or delayed entry should be identifiable and the change clearly and permanently denoted.
Does this checklist tell providers which dose or settings to use?
No. It lists what a complete record contains so you can audit your own charts. Doses, settings and technique come from the treating provider, your medical director, your written protocols and each manufacturer's instructions.
Are before and after photos protected health information?
Full-face photographs are one of the identifiers listed in the HIPAA de-identification standard, so treat them as part of the patient record: store them with the chart, not on personal phones, and get a separate authorization before using them in marketing.
Sources and scope
- CMS Medicare Program Integrity Manual, Chapter 3 (sections 3.3.2.4 and 3.3.2.5)
Services are expected to be documented when rendered; the date and author of any amendment, correction or delayed entry should be identifiable and clearly and permanently denoted. Written for Medicare medical review; cash-pay practices can use it as a reference point.
- 45 CFR 164.514: De-identification of protected health information
Paragraph (b)(2)(i)(Q) lists full-face photographic images among the identifiers.
A documentation completeness checklist, not clinical guidance or legal advice. It does not recommend doses, settings or techniques. Charting, ordering and supervision rules differ by state and payer; confirm requirements with your medical director and a health care attorney.