Risks, benefits, alternatives and the expected result discussed, with a cooling-off period where it applies.
Written consent and photographs on the record.
3Procedure
The product, its batch number and expiry, as recorded in the product log.
The sites treated and the amount at each site, recorded in the treatment chart.
4Findings
What was found or measured, in terms another clinician could act on.
5Complications
Any complication, or a record that there were none.
Anything that did not go to plan, and what was done about it.
6Aftercare and follow-up
Aftercare advice given in writing.
Review appointment arranged.
How the Wai scribe fills it
The same note, written from an invented consultation.
Each line links to the moment in the transcript it came from, and the clinician reads, corrects and signs the note before it is filed.
01Procedure note
SignedAI-assisted, edited by the clinician
Patient
Invented patient, for illustration
Clinician
[Clinician name]
Consultation
In person
Aesthetics procedure note
1Indication
Forehead lines, as assessed. Patient's goal is softening.00:40
2Consent
Completed by the clinician from the record.
3Procedure
Product, batch and expiry recorded in the product log. Sites and amounts recorded in the treatment chart.02:50
4Findings
Mild erythema at injection sites, as expected.07:00
5Complications
Completed by the clinician from the record.
6Aftercare and follow-up
Written aftercare given. Review in two weeks.07:40
Questions
What goes in an aesthetics procedure note?
Indication, Consent, Procedure, Findings, Complications and Aftercare and follow-up. Each section on this page lists what belongs in it, written for aesthetics.
Is the worked example a real patient?
No. The consultation is invented for this page, and no real patient or record is used.
Does the scribe sign the note?
No. The scribe drafts the note from the consultation, and the clinician reads, corrects and signs it, with the time and the change from the draft kept on the record.
Can we use our own note structure?
Yes. Your clinic's own sections are set up once, and the scribe writes each consultation into them.
