Treatment records (charting)

Treatment records are your clinical charting: structured records a provider signs against a specific visit, built from templates you define. Unlike a free-form note, a treatment record captures the same fields every time — injection sites and units, settings, observations, aftercare given — so a client's chart is consistent and defensible.

Setting up templates first

The fields on a treatment record come from an EMR template. Build and manage these under Forms → EMR templates in the menu. A template is a reusable set of fields (text, choices, dates, and so on) for a particular kind of treatment — a neurotoxin record, a laser record, a microneedling record. See Building forms, which uses the same builder.

Signing a record for a visit

There are two ways to start a record, and both land in the same place:

• From the calendar, open the appointment and choose to sign a treatment record — the visit is already filled in for you.
• From the client's Treatment records tab, select + Sign new record and pick the appointment.

Then:

1. Choose the template for the treatment performed.
2. Fill in the fields the template defines.
3. Sign and save. Lumè stamps the record with who signed it and when.

Why records can't be quietly changed

When a record is signed, Lumè freezes a snapshot of both the template and the answers at that moment. If you later edit the template — add a field, reword a question — past records are untouched; they still read exactly as they were signed. If something needs to be added after the fact, you add an addendum rather than altering the original, so the chart keeps an honest history.

Treatment records are protected health information. They're tied to the client and the visit, access follows each person's role, and views are logged.