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Regulation Number: CSL-RGB-008. Documentation.
008.1. Client Information:
- Certificants and licensees shall maintain complete and up-to-date client records that include the client’s personal information, medical history, contact details, and any relevant demographic data.
008.2. Client Assessments:
- Certificants and licensees shall document thorough client assessments, including the client’s health history, current conditions, injuries, and any specific concerns or goals for the treatment session.
008.3. Treatment Plans:
- Certificants and licensees shall develop individualized treatment plans for each client, outlining the treatment goals, techniques to be used, and any modifications based on the client’s condition.
008.4. Treatment Progress:
- Certificants and licensees shall document the progress of each treatment session, including observations, client feedback, techniques applied, pressure used, and any changes in the client’s condition during the session.
008.5. Adverse Events:
- Certificants and licensees shall document any adverse events, complications, or unexpected client reactions during or after treatment sessions, along with the actions taken in response.
008.6. Communication:
- Certificants and licensees shall document any communication with the client, including phone calls, emails, or in-person discussions related to their treatment or progress.
008.7. Client Education:
- Certificants and licensees shall document any educational information provided to the client, including post-session care instructions, exercises, or lifestyle recommendations.
008.8. Timeliness:
- Certificants and licensees shall document client information, assessments, and session notes in a timely manner, preferably immediately after each session to ensure accuracy.
008.9. Signature and Date:
- Certificants and licensees shall sign and date all client records, treatment plans, and session notes to indicate their authorship and the date of documentation.
008.10. Trainer Assessment Documentation
- Educators within the Body Altering Aesthetics industry must maintain documentation compliance of all foundational, supplemental, and core classes. All attendees must complete and post courses assessment to test their knowledge, as well as complete a course review that is to be submitted to the CSL Therapy Council to maintain course and organization accreditation.
Failure to comply with this Patient Privacy/Confidentiality & Public safety regulation may result in disciplinary actions by CSL Therapy, including but not limited to certification or licensure suspension or revocation, dismissal fines, and incarceration in accordance with CSL Therapy’s disciplinary policies and procedures.
This regulation shall be effective as of [September 18, 2023] and shall remain in effect until revised or updated by CSL Therapy.
