Laser Hair Removal Procedure Note

Date: [Date]

Patient Name: [Patient Name]

DOB: [DOB]

Session Number: [Session number of planned series]

Interval Since Last Session: [Interval since last session or N/A if initial] (If not mentioned, insert "Information needed: Interval since last session")

Pre-Procedure Assessment

Fitzpatrick Skin Type: [Type I / II / III / IV / V / VI] — Determination method: [patient-reported burn/tan tendency / clinician assessment] (Do not infer from race/ethnicity. If not mentioned, insert "Information needed: Fitzpatrick type and determination method")

Current Tan Status: [none / mild / moderate / significant] — Sunburn present: [Yes / No] (If not mentioned, insert "Information needed: Tan status and sunburn")

Interval History: [Brief narrative covering adverse events since last session, sun exposure or tanning changes, and relevant medication changes] (For initial session, document "N/A - initial session." If interval history not obtained, state reason explicitly rather than omitting.)

Contraindications Screen:

• Recent tan/sunburn: [Reviewed - findings]
• Keloid/hypertrophic scarring history: [Yes / No] — [Details if positive]
• HSV history: [No history / History without current outbreak / History with current outbreak] (Include only when treating perioral, genital, or other relevant areas)
• Isotretinoin use: [None / Current / Within past X months]
• Other photosensitizing medications: [None / List medications]
• Treatment decision: [Proceed / Defer] — [If deferred, document specific reason and plan]

Consent

Informed consent obtained: [verbal / written / both]. Signed consent location: [EHR location or file reference]. Patient had opportunity for questions. Discussion included: need for multiple sessions with variable response; common expected effects (transient erythema, follicular edema, discomfort); material risks (burns/blisters, hyper/hypopigmentation, scarring, infection, paradoxical hair growth, incomplete response); and alternatives (shaving, waxing, electrolysis, no treatment). Patient agreed to proceed. (If consent not documented in dictation, insert "Information needed: Consent modality and confirmation of agreement")

Safety Attestations

• Protective laser eyewear used by patient and all personnel: [Yes / No] (If not mentioned, insert "Information needed: Eyewear use")
• Laser warning signage and controlled access per facility protocol: [Yes / No]
• Smoke evacuator used: [Yes / No / N/A] — [If No, document rationale]

Procedure Details

(Duplicate the Treatment Area block for each anatomic area treated with different parameters. Use exact device parameters dictated; do not substitute generic settings.)

Treatment Area: [Anatomic site with laterality and boundaries as needed]

Preparation: [Shaving status, skin cleansed, topical products removed] (If topical anesthesia used: agent, concentration, application time, removal time. Omit topical anesthesia details if not used.)

Device and Settings:

• Device: [Manufacturer/model] (If not mentioned, insert "Information needed: Device model")
• Laser type: [Long-pulsed diode / alexandrite / Nd:YAG / IPL / other]
• Wavelength: [nm]
• Spot size: [mm]
• Fluence: [J/cm²]
• Pulse duration: [ms]
• Repetition rate: [Hz / single pulse]
• Cooling: [Contact / chilled gel / cryogen spray / air cooling; setting if applicable]
• Parameter adjustments: [None / Initial settings → Adjusted settings with rationale]

Technique and Endpoints:

• Passes: [Number of passes]
• Pattern: [Overlap approach and technique]
• Observed endpoints: [Perifollicular erythema / follicular edema / hair singeing / none observed]
• Test spot: [Location and response] (Omit if not performed)
• Pain/tolerance: [Pain score 0-10 or tolerance narrative]

Complications: [None / Description with any interventions performed] (If not mentioned, insert "Information needed: Complications statement")

Post-Procedure

Immediate skin appearance: [Expected erythema and edema vs atypical findings]

In-clinic post-care: [Cool compress / topical barrier / topical steroid / none / other] — Patient condition at discharge: [Stable / other]

Aftercare instructions: Delivered via [verbal / printed handout / patient portal]. Standard counseling provided covering: sun protection and tanning avoidance, expected erythema and swelling timeline, activity restrictions, skin care restrictions in treated area, shaving permitted between sessions but no plucking or waxing, expected shedding timeline, and return precautions. (If aftercare delivery not documented, insert "Information needed: Aftercare delivery confirmation")

Tailored instructions: [Patient-specific guidance such as stricter sun precautions, HSV prophylaxis, or wound care] (Omit if none applicable)

Plan

• Next session: [Recommended interval in weeks]
• Parameter adjustments for next session: [None anticipated / Specific adjustments based on today's response]
• Medical indication tracking: [Symptom response] (Include only when treating medically indicated condition such as pseudofolliculitis barbae or hirsutism)

Clinician Signature: [Name, credentials, date/time]