Patient Records and Documentation in Orofacial Harmonization

The patient record is the document that tells the patient's clinical story in your practice. In orofacial harmonization (HOF), it serves three functions that reinforce each other: guiding care (what was done, with what, where), protecting the patient (traceability, handling of complications), and protecting the professional (proof of what was assessed, explained, and consented to).

This guide organizes what to record, how to organize it, and how to keep it. Formal requirements vary among councils and change over time: always check the current rules of your professional council and the applicable legislation in Brazil. We do not cite resolution numbers here; use this text as a roadmap, not as legal advice.

Why does the HOF patient record have particularities?

Three characteristics make documentation in HOF more demanding than in many types of care:

• Elective, aesthetic procedures. The patient's expectation is part of the indication and must be recorded.
• Products with lot and expiration date. Traceability is essential in case of a reaction or recall.
• Images as clinical data. Before and after photos are part of the record and are sensitive personal data.

What to record at the first consultation?

What to record in each procedure?

Each session generates its own record, even if it continues a plan. The essential fields:

For bilateral fillers, record the volume per side. For toxin, remember that units of different products are not interchangeable: the record only makes sense with the product name.

How to document consent?

Informed consent is more than a signature. It documents that the patient received enough information to decide. A good form usually contains:

• the proposed procedure, in plain language;
• goals and limits;
• alternatives, including not treating;
• common risks and rare, serious risks;
• aftercare and warning signs;
• the expected follow-up and the possible need for a touch-up;
• a specific authorization for image use, separate from the clinical authorization.

On the use of photos, see consent and LGPD in patient photos.

How to record complications?

Complications require a detailed record made when they happen, or soon after:

• time of recognition and signs observed;
• management adopted, with products, lots, and times;
• use of hyaluronidase, if any;
• referrals and contacts made;
• instructions given to the patient;
• photos of progression, dated;
• reassessments and outcome.

The complication record serves the patient, the professional who follows them afterward, and your own case review. Preparing the office is covered in hyaluronidase in the office.

How to document the plan and the quote?

The proposed plan and the quote delivered are also part of the patient's story. They show what was recommended, what was accepted, and what was left for later. This is useful when the patient returns months later, asks to "do only part of it", or questions what was agreed.

Record:

• the areas proposed and the suggested order of the stages;
• the alternatives presented, including not treating;
• what the patient chose to do now and what they preferred to postpone;
• the amount and validity of the quote delivered;
• a reference to the projection shown, if any, labeled as a simulation.

Paper or digital patient record?

Both are possible, as long as they meet the rules. Digital makes searching, photo storage, and backups easier, but requires its own precautions.

Whatever the format, avoid records in messaging apps or in your personal phone camera roll. Clinical photos mixed with private photos are a leak risk and make it harder to prove authenticity.

How long should it be kept?

The minimum retention period for the patient record is set by law and by each council's rules. Check the current rule for your profession. When in doubt, keep it longer, securely. Clinical photos are part of the record and follow the same period.

What about the LGPD?

The patient record contains sensitive personal data, including health data and facial images. The LGPD (Brazil's Law No. 13,709/2018, available at Planalto) requires a legal basis for processing, adequate security, and respect for the patient's rights. Practical points:

• access restricted to those who need it, with an individual password;
• protected backups;
• care when sending documents by message or email;
• a log of who accessed the record, when the system allows;
• an organized response to patient requests, such as a copy of the record.

Who can access the patient record?

The patient record belongs to the patient as far as the right of access to the information is concerned, and keeping it is the responsibility of the professional or the service. In practice:

• the patient can ask for a copy of the information, and the clinic must have a procedure to handle it;
• the staff access only what is needed for their role, with an individual password when the system is digital;
• third parties, such as family members or other professionals, only with the patient's authorization or in the cases provided by law;
• other professionals at the clinic who see the same patient must record their own visits, identified.

In clinics with several professionals, agree in writing on who is responsible for retention and how the records are signed.

What are the most common documentation mistakes?

• Generic entries, such as "lip filler performed", with no product, lot, or volume.
• Blank fields instead of negative answers.
• Photos with no date or no patient identification.
• Generic consent, that does not name the procedure performed.
• Image authorization embedded in the clinical form, with no option to decline.
• Records made days later, with details lost.
• Complications recorded only as "resolved", with no signs, times, or management.
• Records scattered across paper, a messaging app, and a personal phone.

Where does Harmy fit into documentation?

Harmy stores in History, per patient, the before photo of each session, the plan with the volume per area, and the generated projection, which is an illustrative simulation. With "Add actual result", you save the result photo aligned by the eyes and compare Projection vs Actual. The quote as a PDF records what was proposed, with values per ml and validity.

These records are useful for documenting the conversation about expectations and what was proposed. They do not replace the clinical patient record: product, lot, units, instrument, medical history, consent, and complications go in your patient record. If you attach the projection to the patient record, label it as a simulation. See history and actual result and quote as a PDF.

HOF patient record checklist

1. Complete identification and emergency contact.
2. Chief concern in the patient's own words.
3. Complete medical history, updated at every session.
4. Assessment by area, with asymmetries recorded.
5. Standardized before photos, dated.
6. Proposed plan, alternatives, and expectation.
7. Signed consent, with a separate image authorization.
8. Product, lot, expiration date, quantity, area, and instrument in each procedure.
9. Complications and management, with times.
10. Instructions delivered and follow-up scheduled.
11. Secure retention, with backup and restricted access.

For photos that are comparable across sessions, see standardized clinical photography.