Client Consultation and Documentation
What the exam tests
Consultation and documentation questions test informed consent, medical-history screening, patch testing, SOAP-style notes, privacy, and professional communication. The exam expects you to know when to decline or refer.
Core rules
- Intake: allergies, medications such as isotretinoin, retinoids, blood thinners, and photosensitizers; pregnancy; surgeries; skin conditions; prior peels or waxing; and home products.
- Informed consent: explain the service, products, risks, alternatives, expected aftercare, and the right to stop; obtain a signature and date. Verbal permission alone is weak documentation.
- Patch test: apply product to a small area, often behind the ear or inner forearm, observe for 24 to 48 hours, and document. Follow manufacturer and Ohio rules for waxing and chemical services.
- SOAP note: Subjective is the client's words; Objective is visual and palpation findings; Assessment is what you observe and your service plan, not a medical diagnosis; Plan is products, service, aftercare, and follow-up.
- Document adverse reactions, incident reports, product names and lots, and referrals; keep records confidential and secure.
- Use plain language, avoid promising cures, respect modesty and boundaries, and refer medical concerns.
Worked example
A client requests a lip wax and notes she started isotretinoin two months ago. Reasoning: isotretinoin thins and sensitizes skin; waxing can avulse skin. Do not wax. Explain, document the refusal and referral to her prescriber, and offer only a safe alternative if approved.
Traps
- Relying on a verbal I'm not allergic.
- Writing a diagnosis such as client has rosacea instead of an observation.
- Skipping aftercare instructions.
- Discussing a client's information in a public area.