A patient record has two readers. One is the next provider, who should be able to continue a treatment without calling you. The other is anyone who later asks what was done: the patient, a regulator, or you, years from now.
Both need the same things: a record written the same way every time, signed by the person responsible, never quietly changed, and read only by people who should. This guide covers the habits behind each, on paper or in software.
Write every visit from a template
Records go wrong when each provider writes in their own style, because the next reader can't tell a missing detail from one nobody checked. Agree on a structure for each kind of visit and use it every time.
- A consult might cover the complaint, history, findings, and the plan.
- A treatment, such as a peel or a filler session, might cover the area, the settings or units, the products used, and how the patient tolerated it.
- A follow-up might cover progress since the last visit and any change to the plan.
Write during or right after the visit. Details recalled at 7 PM are rarely the ones you needed. In Onsuki's Charting, you set note templates and a default template for each service, and a chart entry can start itself when a chosen service is booked, so the provider opens a ready entry instead of a blank page.
Record what you used, down to the lot
If a product is recalled or a patient reacts, the question is which patients received that batch. You can only answer it if the lot is on every record, not just the product name.
- Note the product and the amount or units given.
- Note the lot number and its expiry date.
- Note where it was given, if that matters for the treatment.
In Onsuki, the provider picks the product from your inventory on the chart entry, and the lot number and expiry are read from the lot, not typed. If the chosen lot has expired, the entry says so.
Keep the medical summary current
Allergies, current medications, and conditions should be the first thing a provider sees, not something on page three of an old intake. Review them at every visit, and update them when the patient tells you something new.
Onsuki keeps a medical summary on each patient's chart. When a patient answers an intake form, the answers are proposed for the summary as unticked rows, so nothing joins the summary until someone on your team has checked it and ticked it. See how to set up intake forms.
Sign entries, and amend instead of overwriting
A signed entry says who is responsible for it. After that, it should not change silently: if something was wrong or missing, add an amendment that says what changed and why, and keep the original. A record that can be edited without a trace proves nothing.
- Sign each entry yourself. Never share a login or sign for a colleague.
- Amend with a reason, such as "Corrected units, typed 20 instead of 2".
- Keep consents and before and after photos with the entry they belong to.
In Onsuki, a provider signs an entry with their PIN or Face ID, and the signature carries their name, profession, and PRC number from their account. A signed entry changes only by an amendment, which records the change and the reason.
Give each person the access their job needs
Your front desk needs a patient's mobile number and next appointment, rarely their history. Giving everyone full access is easy on day one and hard to undo later, so start narrow.
| Practice | Why it matters |
|---|---|
| Separate viewing, signing, and exporting | Reading a chart, signing one, and sending one out are different responsibilities |
| Lock a shared tablet when it's left alone | The next person to pick it up shouldn't see the last chart |
| Keep a log of who opened what | You can answer when a patient asks who saw their record |
| Record a reason for every copy sent out | You know where each copy went and why |
In Onsuki, only the owner starts with chart access. You grant each person what they need: viewing the charts where they are the provider, or everyone's; signing; and exporting. Chart pages lock after five minutes without a touch and open again with the signing PIN. The owner sees an access log for each entry, and every PDF download asks for a purpose.
Ask for consent by purpose
Keeping health records, taking clinical photos, and using photos in your marketing are three different requests. Ask for each one separately, record what the patient agreed to and when, and act on a withdrawal.
Onsuki shows each purpose on the patient's chart with its current state, such as agreed or withdrawn, and says what a withdrawal changes: existing records stay, new clinical photos can't be added, and their photos can't be used in marketing. Read the Data Privacy Act of 2012 and the National Privacy Commission's guidance, and ask your lawyer what applies to your clinic.
Set how long you keep records
Choose one retention period for your clinic, write it down, and apply it to every patient. Your professional body or your lawyer can tell you what yours should be.
In Onsuki, you choose to keep records for 7, 10, 15, or 25 years, counted from the patient's last visit. A patient whose records must still be kept can't be deleted. Their records can be restricted instead, so only the owner can open them. Charting is on the Clinic plan: see Pricing.
