Medical Aesthetics Follow-Up/Progress Note

Date/Time: [Date and time of encounter]

Provider: [Provider name and credentials]

Location: [Clinic/site]

Visit Type: [routine follow-up / complication evaluation / touch-up]

Prior Treatment Reference: [Date and type of prior treatment being followed] (If unknown, document as "unknown." If multiple prior treatments, list most recent first.)

Chief Concern

[Patient-stated reason for visit and aesthetic goals; include direct quote if available] (Limit to 1–3 lines.)

Interval History

(Use brief narrative or bullets. When details are unavailable, state "unknown" rather than omitting.)

• Treatments since last visit: [Dates, areas, products/devices, provider/setting] (Label as patient-reported when not verified.)
• Treatment response: [Onset timing, peak effect, duration, current status: full effect / partial / worn off / uneven]
• Patient satisfaction: [Naturalness, symmetry, duration, goal attainment]
• Adverse effects: [present / absent / not assessed] (If present, describe symptoms, timing, care sought, and current status. Never leave blank.)
• Relevant medical updates: [New medications, allergy changes, pregnancy status, autoimmune activity] (Omit this line entirely if no relevant updates.)

Objective

Exam: [Focused aesthetic exam of relevant regions documenting symmetry at rest and animation, rhytid severity, volume/contour, skin quality, and palpation findings; include comparison to prior exam or baseline photos with date reference]

Photos: [obtained today / not obtained] (If obtained, note views captured and confirm images stored in medical record. State clinical photography consent status. If separate marketing/educational authorization exists, note on file. If not obtained, state reason.)

Assessment

(Use numbered, problem-oriented format: 1) complications if present, 2) aesthetic concerns by region, 3) skin health. Note trend for each.)

1. [Complication or "No complications"]: [Description if applicable]; [improving / stable / worsening]
2. [Aesthetic concern – region]: [Description]; [improving / stable / worsening]
3. [Skin health consideration]: [Description]; [improving / stable / worsening]

(Add or remove problems as needed.)

Plan

(For each assessment problem, document plan type, options discussed, risk counseling, and follow-up.)

• Problem [#]:
  • Plan: [maintenance at usual interval / adjustment] (Include rationale for any changes.)
  • Options discussed: [Treatment options including no treatment]
  • Risk counseling: [Modality-specific risks and return precautions reviewed]
  • Follow-up: [Timeframe or date]
• Procedure (Include only if procedure performed today.)
  • Consent: [Informed consent obtained; risks, benefits, alternatives discussed; patient understanding confirmed]
  • Product traceability: [Product name], [Lot/batch #], [Expiration], [Total amount used] (If lot/expiry unavailable, document as missing.)
  • Technique: [Anatomic sites with laterality, dose/volume per site, depth/plane, needle or cannula gauge] (For devices: [Device name, settings, passes, endpoints].)
  • Immediate outcome: [Patient tolerance, expected vs concerning findings, any complications and actions taken]
  • Post-procedure instructions: [provided / not provided]; [Red flag symptoms reviewed]
• Treatment deferred: [Reason] (Include only if applicable.)