A good faith exam compliance checklist helps med spas verify that every required step has been completed before prescription-only aesthetic treatment begins. Reviewing provider qualifications, patient evaluations, documentation, and renewal schedules helps identify compliance gaps before they become regulatory issues. Because good faith exam requirements vary by state, every practice should confirm that its checklist reflects the laws and professional standards governing its location.

Complete Good Faith Exam Compliance Checklist

A good faith exam should follow a consistent process from the initial patient evaluation through documentation and renewal tracking. Working through this checklist helps confirm that your practice has addressed the core elements commonly reviewed during compliance audits. Because requirements differ by state, verify that each item aligns with the laws and regulations governing your practice.

1. Confirm the Provider Is Authorized to Perform the Exam

The first step is confirming that the provider conducting the good faith exam has the legal authority to perform the evaluation. Provider qualifications differ by state, particularly for nurse practitioners, physician assistants, physician delegation, and telehealth examinations.

Verify that:

• The provider holds an active professional license: Confirm the provider’s license is current and in good standing with the appropriate licensing board.
• The provider has the authority to evaluate the patient and authorize treatment: State law determines which healthcare professionals can independently perform a good faith exam.
• Required physician collaboration or delegation is documented: If your state requires physician oversight, verify that collaborative agreements or delegation protocols are current and reflect the services being provided.

2. Complete the Medical History Review

A complete medical history helps the provider determine whether treatment is clinically appropriate and identify factors that could affect patient safety. Every evaluation should gather enough information to support an informed clinical decision before treatment begins.

Verify that the record includes:

• Current medications and supplements: Identify medications that could interact with treatment or increase the risk of complications.
• Allergies and previous adverse reactions: Document known allergies or prior reactions to medications, fillers, or other aesthetic treatments.
• Existing medical conditions: Review chronic illnesses or other health concerns that could influence treatment planning.
• Previous cosmetic procedures: Understand prior treatments that could affect results or increase procedural risks.
• Other treatment-specific health information: Gather additional information relevant to the planned procedure.

3. Perform a Focused Physical Examination

The physical examination confirms that the patient’s condition supports the planned procedure. Instead of relying only on medical history forms, the provider should assess the treatment area and document clinical findings relevant to the service being performed.

Verify that the examination documents:

• The condition of the treatment area: Evaluate the skin, tissue, or anatomy relevant to the procedure.
• Clinical findings that support treatment planning: Record observations that influence the provider’s recommendation.
• Contraindications or precautions: Identify infections, inflammation, injuries, or other findings that could delay or prevent treatment.
• Overall treatment candidacy: Document whether the patient is medically suitable for the requested procedure.

4. Document the Clinical Decision

A good faith exam concludes with a documented clinical decision. The patient’s record should clearly explain whether treatment should proceed and the clinical reasoning supporting that recommendation.

Verify that the provider documents whether to:

• Proceed with treatment: The patient is an appropriate candidate, and treatment can move forward.
• Modify the treatment plan: Changes are recommended to improve safety or achieve a better clinical outcome.
• Delay treatment: Additional evaluation or medical management is needed before treatment begins.
• Decline treatment: Clinical findings indicate that the planned procedure is not appropriate.

5. Obtain Informed Consent

A good faith exam and informed consent serve different purposes but work together to support compliant patient care. Once the provider determines that treatment is appropriate, the patient should receive the information needed to make an informed decision.

Confirm that documentation includes:

• Treatment risks and potential complications: Explain the known risks associated with the planned procedure.
• Expected benefits: Discuss realistic treatment goals and anticipated outcomes.
• Available alternatives: Review other treatment options when appropriate.
• The patient’s informed agreement: Confirm that the patient understands the information provided and agrees to proceed.

6. Review Documentation Before Treatment

Complete documentation demonstrates that the required evaluation occurred before treatment was provided. Reviewing the patient’s chart before the appointment also helps identify missing information that should be addressed before proceeding.

Before treatment, verify that the chart contains:

• Medical history documentation: A complete record of the patient’s relevant health information.
• Physical examination notes: Clinical findings from the provider’s evaluation.
• Clinical assessment: The provider’s determination regarding treatment candidacy.
• Treatment recommendation: The proposed treatment plan or documented alternative.
• Required signatures or acknowledgements: Documentation required by your state’s laws or your practice’s internal policies.

7. Track the Next Required Evaluation

Completing the first good faith exam is only part of maintaining compliance. Practices should also monitor when another evaluation is required based on state law, changes in the patient’s health, or the addition of new treatments.

Track:

• The date of the current evaluation: Maintain an accurate record of when the examination was completed.
• The next required evaluation: Schedule follow-up examinations before the current evaluation expires, when applicable.
• Changes in the patient’s health: Update evaluations when new medical conditions or medications could affect treatment.
• New treatments or services: Perform another evaluation when a different procedure requires a new clinical assessment.

Turn Your Checklist Into a Written Policy

Completing a checklist is only part of maintaining compliance. The next step is turning those individual tasks into a written policy that every provider and staff member follows consistently. A documented process reduces variation, clarifies responsibilities, and provides evidence that the practice has established standardized compliance procedures.

Your written policy should address:

• Who performs the good faith exam: Identify the providers authorized to perform patient evaluations under your state’s laws and define when physician collaboration or delegation applies.
• When the exam is required: Specify when patients must complete a good faith exam before treatment and identify situations requiring another evaluation, such as new services or significant health changes.
• How the evaluation is documented: Establish consistent documentation standards so every provider records the information needed to support the clinical decision.
• When informed consent is obtained: Explain how informed consent fits into the patient workflow after the provider determines that treatment is appropriate.
• Who oversees compliance: Assign responsibility for reviewing documentation, monitoring renewal dates, and updating policies as state requirements or practice services change.

Practices operating in more than one state should maintain policies that reflect the specific laws governing each location, particularly regarding provider authority, physician delegation, telehealth evaluations, and renewal requirements.

Track Good Faith Exam Renewals

A compliant good faith exam process does not end after the patient’s first visit. Practices should also monitor when another evaluation is required so patients do not receive treatment based on outdated medical information or expired compliance documentation.

An effective renewal tracking process should include:

• The date of the most recent evaluation: Record when the good faith exam was completed so future reviews can be scheduled appropriately.
• The next required evaluation date: Track renewal deadlines based on state law, physician protocols, or your practice’s internal policies.
• Changes in the patient’s medical history: Review patients again when new medications, diagnoses, or health conditions could affect treatment safety.
• New treatments or services: Complete another good faith exam when a patient begins a treatment requiring a different clinical assessment or when state law requires another evaluation.

Many practices perform annual good faith exams as part of their compliance program. However, renewal frequency varies by state, and some treatments or changes in a patient’s health may require an earlier examination. Practices should confirm the applicable requirements before establishing their renewal schedule.

How Medical Director Co. Helps You Pass This Checklist Every Time

A compliance checklist is most effective when it is supported by qualified physician oversight and clearly documented clinical processes. Medical Director Co. helps med spas establish those systems by matching practices with qualified physicians and providing documentation that supports compliant patient evaluations.

Every placement includes:

• Qualified physician matching: Physicians selected based on your state’s physician oversight requirements and the services your practice provides.
• Attorney-reviewed agreements: Documentation defining physician oversight, delegation, and clinical responsibilities.
• State-specific compliance support: Guidance that reflects your state’s provider authority, delegation, and good faith exam requirements.
• Ongoing physician oversight: Continued support as your practice adds providers, expands services, or updates clinical protocols.

Medical Director Co. helps practices build physician oversight processes that support consistent, well-documented good faith exams and long-term compliance.