How to record patient concerns in the patient's own words
Quick facts
- Practice
- Write the concern in the patient's own words, in quotation marks
- Benefit
- An objective basis for assessing the result at the follow-up
- Where
- Patient record, alongside the medical history and the assessment
- Caution
- Record what was said, without interpreting or judging
"I feel like I look tired." "My chin disappears when I smile." "I want to look prettier, without changing." Each of these sentences says more about what the patient expects than any procedure code. Recording them in the patient's own words seems like a detail, but it is one of the practices that helps most at the follow-up: it gives an honest yardstick for assessing the result. This page shows why and how.
Why do the literal words matter?
Because the patient judges the result with their own language and their own lens, not yours. If you write "deep nasolabial fold" and the patient said "I want to get rid of this line on my smile," at the follow-up you may be assessing different things. The patient's word is the criterion. Recording the words also prevents the "I never said that" doubt and shows the patient they were heard. See active listening in the HOF consultation and open-ended questions for the consultation.
How do you record it in practice?
Split it into two fields: what the patient said and what you assessed. This avoids mixing the account with interpretation.
| Field | Content | Example |
|---|---|---|
| Literal concern | The patient's words, in quotation marks | "I look angry even when I'm relaxed" |
| Stated expectation | What the patient expects, in their words | "I want my face to look lighter" |
| What the patient does not want | Declared limits | "I don't want anyone to notice" |
| Professional's assessment | What you observed | Expression lines in the glabella, downturned mouth corner |
| Agreed priority | What will be treated now | First stage: glabella area |
This format also helps build the plan summary. See one-page plan summary and patient's priority list.
How does this help at the follow-up?
At the follow-up, the natural question is "do you like it?" The better question is "remember you said you felt like you looked tired? How do you see yourself now?" The recorded concern turns the follow-up from a subjective conversation into a concrete comparison. When the patient is dissatisfied, it helps you understand why. When the patient is satisfied, it shows what worked. See follow-up with a dissatisfied patient, follow-up with a satisfied patient, and follow-up consultation, what to say.
What should you avoid when recording?
- Translating immediately into a technical term, losing the patient's words.
- Labeling the patient ("demanding," "difficult," "neurotic").
- Copying phrases from templates unrelated to what was said.
- Recording only what you want to treat, ignoring what the patient wants.
- Keeping personal comments that do not help care and that the patient could read.
What about photos and the simulation?
Photos and simulations are patient data, including sensitive data, and must be handled according to the LGPD and what the patient authorized. Also note that the simulation was shown as an illustration. If the literal words include something about privacy ("I don't want anyone to know"), write it down and respect it. See will it show that I had work done and security of patient images in the simulation.
How do you turn this into a routine?
Define a short template and always use the same one. A good format takes less than three minutes and already works for the whole team: literal concern, stated expectation, declared limits, and assessment. Train whoever does the pre-consultation to take notes the same way. See training the team in patient communication.
Recording the patient's words is an act of respect and a clinical tool. Months later, it shows where the two of you were heading together.
What if the patient cannot say what they want?
Not every patient can put their discomfort into words. Help with concrete questions: "In which photo do you not like yourself?", "What do you see when you look at yourself in the morning?", "When do you feel most confident about your face?" The answers become sentences you can record. If the patient only says "I want to improve," record exactly that and add what the patient pointed to in the mirror.
A lack of words is also information. It may indicate diffuse insecurity, outside pressure, or the absence of a real clinical concern. Note this neutrally and lead calmly, without filling the void with procedures. See indecisive patient and how to use the mirror in the consultation.
When writing, prefer to quote the patient's phrase in quotation marks and to keep what the patient said separate from what you observed. Reread the record with the patient before finishing, to confirm that the concern was understood, and keep the date to compare at follow-ups. The decision on how to proceed remains clinical and individual.
Frequently asked questions
Why record the concern in the patient's own words?
Because at the follow-up you can compare the result with what the patient wanted, in the patient's terms, and not with your interpretation.
Do I need to write down everything the patient says?
No. Note the main concerns, the expressions the patient used, and what the patient said they expect. A good literal summary is worth more than a long text.
Can I record the consultation to capture what is said?
Recording involves consent and the rules of your professional board and of the LGPD (Brazil's General Data Protection Law). In general, taking notes is simpler. See the page on the patient who wants to record the consultation.
How do I avoid over-interpreting the concern?
Write first what the patient said, in quotation marks, and only afterward your own assessment, in a separate field.
Harmy images are illustrative simulations generated by AI from the patient's photo to support the conversation between practitioner and patient. They are not a promise of results. Indication, technique, product and volume are solely the decision of the licensed practitioner. This content is for information only and does not replace a clinical assessment.