Patient follow-up and progress form template
The follow-up and progress form is the record of each visit after the procedure: what the patient reported, what you observed, what you decided to do (or not to do) and when they return. It tells the story of the treatment over time and protects both the patient and the professional when it is necessary to reconstruct what happened.
This template complements the record of the day of the injection. For what makes up a complete patient record, read patient records and documentation in HOF, and to organize the review visit, clinical follow-up consultation.
When should you use this template?
At every scheduled follow-up (a 15-day review, for example), at a follow-up for a concern, at a touch-up and at relevant contacts by phone or message. Fill it in the same day, while the memory is fresh, and attach the photos. Do not leave it for later: a form reconstructed from memory is worth less.
How do you adapt it?
- Adjust the fields to what you do. Someone who works only with toxin does not need the filler volume fields.
- Standardize the photos. The same distance, light and angles at each visit allow comparison. See standardized clinical photography.
- Record the product and lot of each injection, including touch-ups, according to your routine. See injectable traceability.
- Note the decision not to intervene, when that is the case, with the reason. That is also management.
- Write facts, not adjectives. "Mild swelling in area X" informs; "it looks ugly" does not.
- Agree on the next follow-up date with the patient and use the follow-up calendar so you do not lose contact.
What can never be missing?
| Item | Reason |
|---|---|
| Date, identification and professional | Traces who treated and when |
| Reference procedure and injection date | Places the progress in context |
| Patient's concerns and perception | Records the reported experience |
| Complications and their progress | Shows management and follow-up |
| Assessment findings | What you observed, in objective language |
| Standardized photos | Comparison over time |
| Management, touch-up and instructions | What was done and said |
| Next follow-up | Continuity of care |
Follow-up and progress form template
How long should the form be kept?
The retention period for the patient record is set by regulation and varies by professional category and type of service. Confirm it with your council and a lawyer, and store it in a place with controlled access, on paper or in a system. Health data and photos are sensitive data: see LGPD and consent and LGPD for photos.
Frequently asked questions
What should be recorded on the follow-up form of a harmonization patient?
Date, the patient's concerns and perception, complications since the last visit, assessment findings, standardized photos, management (including the decision to do nothing), touch-up if any, product and lot used, instructions given and next follow-up. Record what was observed and decided, without giving opinions outside your competence.
Do I need a progress form at every follow-up?
It is advisable to record every visit in the patient record, even quick ones. The exact requirement varies with your professional council, so confirm the record-keeping rules for your category. A short record of each contact is better than none.
Can I keep the patient's photos in the progress form?
Yes, as part of the patient record and to follow the case, informing the patient and protecting the data under the LGPD (Brazil's General Data Protection Law). Using the images in promotion requires separate, specific authorization and compliance with your council's rules.