Aesthetic Procedure Complication Visit Note

Encounter Date: [Date]

Start Time: [Start time] (Document exact time; if approximate or unknown, state as such with reason.)

End Time: [End time]

Encounter Type: [in-person / telehealth / telephone]

Clinician: [Clinician name and credentials]

Source of History: [Patient / caregiver / records / combination]

Chief Complaint

[Single-line primary concern with relevant context]

Index Procedure

Procedure: [Procedure type] at [anatomic site(s)]

Date/Time Performed: [Date and time] ([Time since procedure])

Operator: [This clinic / Outside clinic / Unknown]

Product/Device: [Name, volume/units, lot number if available] (If unavailable, state "Unknown" with reason.)

History of Present Illness

[Patient-reported history of the complication as a focused narrative paragraph. Include onset with specific date/time; progression; character of symptoms including pain quality/severity, swelling, color changes, drainage, sensory changes, and functional impact. Screen for red flags appropriate to presentation: for facial procedures, address visual symptoms; for infections, note fever/systemic symptoms; for suspected vascular events, document blanching, livedo pattern, or disproportionate pain. Include self-treatment attempted, prior contacts with clinic, and patient's primary concerns. When critical details cannot be obtained, state why.]

Objective

Vitals: [Relevant vitals, or "Not obtained" with reason if telehealth]

General: [Appearance and distress level]

Targeted Exam: [Findings at affected site using precise anatomic terms and measurements: color/perfusion, edema, warmth, induration, fluctuance, drainage, tenderness, sensation; compare to contralateral side when relevant. For suspected vascular compromise, include capillary refill time in seconds and any ocular screening performed.]

Photos: [Photos obtained today with consent status and storage per policy, or "None obtained"]

Data Reviewed: [Labs, cultures, imaging, outside records, patient-submitted photos with date/time if known] (Omit if none.)

Assessment

[List problems in order of urgency. For each, state working diagnosis, severity/acuity (mild/moderate/severe; stable/improving/worsening), and key supporting findings. Include differential when it affects management. For time-sensitive concerns such as suspected vascular occlusion or vision symptoms, explicitly document level of concern and rationale.]

Plan

[Organize by problem. For each, address: immediate interventions performed today; medications prescribed with indication; diagnostics ordered; consultations/referrals made (who contacted, when, outcome). If procedure performed today, briefly document consent, technique, and outcome or reference separate procedure note.]

Patient Education: [Topics covered]

Return Precautions: [Vision change, spreading redness, fever, worsening pain, skin darkening, other relevant warnings]

Follow-up: [Timeframe and modality] | After-Hours Contact: [Instructions given]

Disposition: [Routine follow-up / ED transfer / Same-day specialty referral] (If urgent, document clinical rationale, transport, and condition at disposition.)

(If billing by time, document total clinician time on encounter date. If billing by MDM, ensure documented elements support complexity level.)