Headings
Event description · Onset and timeline · Treatment involved · Assessment · Management · Escalation and referral · Patient communication · Follow-up
When to use it
Use this whenever a treatment causes harm or a suspected complication, from a mild reaction to an emergency. It lays out the timeline, what you did and what you told the client, which protects both of you. Write it the same day, separate from the treatment note.
Example
Fictional example
Event description
K.D., 50F. Suspected vascular occlusion after hyaluronic acid filler to the left nasolabial fold.
Onset and timeline
Blanching noted 2 minutes after injection. Mottled, dusky skin by 10 minutes. Pain 6 out of 10.
Treatment involved
Hyaluronic acid filler, lot 000-TEST, 0.4 mL by needle to the left nasolabial fold.
Assessment
Slow capillary refill over the left upper lip and ala. Vision normal. No neuro signs.
Management
Injection stopped. Hyaluronidase 1,500 units flooded across the area. Warm compress and massage. Refill improved by 60 minutes.
Escalation and referral
Supervising physician on site. Ophthalmology on standby, not needed.
Patient communication
Explained the event and treatment. Written warning signs given. Mobile number provided.
Follow-up
Phone check tonight. Clinic review tomorrow morning and at day 3.