Documentation of Treatment: Botulinum Toxin

Abstract

Anatomic documentation of treatment sites creates a historical record upon which further treatment modifications may be individualized. For example, if a patient has inadequate lateral forehead wrinkle reduction, one may refer to the treatment diagram and use this as a basis for adding new lateral treatment sites.

Reprinted from Chen WPD, Khan JA, McCord, Jr, CD. Color Atlas of Cosmetic Oculofacial Surgery. Philadelphia, PA: Butterworth Heinemann/Elsevier; 2004. With permission from Elsevier.

Anatomic documentation of treatment sites creates a historical record upon which further treatment modifications may be individualized. For example, if a patient has inadequate lateral forehead wrinkle reduction, one may refer to the treatment diagram and use this as a basis for adding new lateral treatment sites (Fig. 118.1).

Fig. 118.1

Sample chart note and diagram for botulinum toxin therapy

While botulinum toxin A appears to be a safe and effective drug, the very long-term consequences of neurotoxin injection are unknown. Therefore, informed consent is important despite the relative simplicity of the procedure. Informed consent discussion should include both the known side effects and unknown risks related to the use of human albumin in botulinum toxin A.

Lifetime Consent for Administration of Botulinum Toxin

• 1. I, ____________ ____________ (first name, last name), request that Dr. ____________, or whomever he designates, administer botulinum toxin to me for either medical or cosmetic purposes. Botulinum toxin is not FDA approved for headache treatment, tarsorrhaphy, or muscle twitching. Photos of me may be taken and used for educational, scientific, or marketing purposes.

• 2. If botulinum is given for medical purposes, such as involuntary muscle spasm, tarsorrhaphy, blepharospasm, hemifacial spasm, muscle twitch or tick, etc., I hereby acknowledge that I understand that there may be alternative treatments for this condition, including, but not limited to, medical therapy including the administration of oral medicines, muscle stripping or other operations, removal of motor nerves, or procedures to release pressure on involved nerves.

• 3. I acknowledge that I understand that botulinum toxin A includes human albumin. Albumin is a protein, similar to the white of a chicken egg, that is derived from human blood products. While it is not believed that there has been any transmission of diseases from botulinum toxin A, I understand that this is very unlikely but possible. I accept the risk of the possibility of acquiring an infection, including viral or other types of infections from botulinum toxin administration, and accept the risk of unknown future complications from botulinum toxin use. I understand that botulinum B can also be used for my condition and does not contain albumin.

• 4. Botulinum toxin usually works well in 95 % of patients. There is a 5 % chance that it will not have an adequate effect. It is not always possible to predict the effect, and it may work too well or not well enough. Some of the side effects may include flu symptoms, headache, temporary droopiness of one or both eyelids, or double vision. Permanent muscle weakness is very unlikely.

• 5. By signing this document, I agree that it includes all botulinum toxin injections already provided by Dr. Khan or whomever he designates, as well as all future botulinum toxin treatments.

• 6. I understand that the effects of botulinum toxin use with pregnancy or breast-feeding are not known and that I should not take botulinum toxin if the possibility of pregnancy or nursing exists.

• 7. In summary, the risks, consequences, benefits, and alternatives of treatment, including no treatment, have been explained to me.

  Signed (Patient) ____________ Date ____/____/03

  Witnessed By ____________ Date ____/____/03