Charting a good faith exam follows the same documentation standard as any other patient encounter. The medical record should document the patient’s history, clinical findings, assessment, and treatment plan that support the provider’s decision before a prescription-based treatment is performed. Because good faith exam requirements vary by state, practices should also verify applicable documentation requirements.
Key Takeaways
- Chart a good faith exam using the same SOAP, which stands for Subjective, Objective, Assessment, and Plan, note structure as any other patient encounter. (Jump to Section)
- The assessment and treatment plan should clearly explain why treatment was approved or declined. (Jump to Section)
- A checklist or abbreviated note does not replace a complete clinical record. (Jump to Section)
- Standardized EHR templates help providers document good faith exams consistently across the practice. (Jump to Section)
- Medical Director Co. helps med spas establish physician oversight and documentation processes that support compliant operations. (Jump to Section)
Structuring a Good Faith Exam Note
A good faith exam should be documented using the same SOAP (Subjective, Objective, Assessment and Plan) format used for other medical encounters. Following a consistent structure helps create a complete clinical record and makes documentation easier to review.
Subjective (S)
The subjective section captures the patient’s medical history and the information they provide during the evaluation. It establishes the clinical context for the provider’s assessment and treatment decision, including:
- Chief concern: Why the patient is seeking treatment.
- Medical history: Relevant medical conditions, previous procedures, and past treatment outcomes.
- Current medications: Prescription medications, over-the-counter products, and supplements.
- Allergies: Drug allergies and other relevant sensitivities.
- Patient concerns and goals: Information that helps guide the clinical evaluation and treatment discussion.
Objective (O)
The objective section documents the provider’s clinical findings from the examination. Unlike the subjective section, it focuses on observable facts rather than information reported by the patient. These findings support the provider’s assessment and treatment decision by documenting:
- Physical examination: Findings relevant to the planned treatment.
- Observable conditions: Skin quality, anatomical findings, or other clinical observations.
- Vital signs or measurements: Record when appropriate for the treatment being performed.
- Supporting documentation: Photographs or other clinical records maintained as part of the patient’s chart, when applicable.
Standardize Good Faith Exam Documentation
Qualified medical directors with ongoing compliance support.
Where Clinical Documentation Matters Most
The assessment and plan explain the provider’s clinical judgment and show why treatment was appropriate. If the record is ever reviewed, these sections demonstrate that the treatment decision was based on a documented medical evaluation rather than a checklist.
Assessment (A)
The assessment should summarize the provider’s clinical conclusions based on the patient’s history and examination. It should explain whether the patient is an appropriate candidate for treatment and identify any factors that affect that decision. The assessment should document:
- Clinical impression: The provider’s findings after evaluating the patient.
- Treatment eligibility: Whether the planned procedure is appropriate based on the evaluation.
- Contraindications or precautions: Medical conditions, medications, or other findings that require additional consideration.
- Clinical reasoning: The factors that support approving, modifying, delaying, or declining treatment.
Avoid chart entries that simply state “patient cleared” or “approved for treatment.” The assessment should explain how the provider reached that conclusion.
Plan (P)
The plan documents what happens after the evaluation. It should clearly describe the treatment decision and any follow-up instructions. The plan should include:
- Treatment recommendation: The procedure approved or deferred.
- Patient education: Risks, benefits, alternatives, and post-treatment instructions discussed with the patient.
- Informed consent: Documentation that informed consent was obtained before treatment.
- Follow-up care: Return visits, monitoring, or additional evaluations when appropriate.
- Referral or additional testing: If treatment is postponed pending further evaluation.
A complete treatment plan allows another provider reviewing the chart to understand exactly what was decided and why.
Building a Standard Good Faith Exam Template
A standardized EHR template helps providers document good faith exams consistently while reducing incomplete records. Instead of relying on free-text notes or abbreviated forms, build the template around the SOAP structure used for every patient encounter.
Your template should prompt providers to document:
- Patient history and current concerns.
- Relevant examination findings.
- Clinical assessment supporting the treatment decision.
- Treatment plan, informed consent, and follow-up instructions.
- Provider signature and date.
Templates should improve consistency, not replace clinical judgment. Every note should be completed using the patient’s individual history and examination findings rather than copied from previous encounters.
State documentation requirements vary. Review your template regularly to confirm it reflects current physician oversight, delegation, and documentation requirements where your practice operates.
How Medical Director Co. Supports Consistent Good Faith Exam Charting
Medical Director Co. helps med spas establish physician oversight that supports standardized documentation across every provider and location.
Our physician placement service includes:
- Qualified medical directors: Physicians experienced in med spa oversight and state-specific compliance requirements.
- Attorney-reviewed agreements: Documentation prepared to support compliant physician relationships.
- Ongoing compliance support: Guidance as documentation requirements, treatment offerings, and regulations change.
- Fast physician placement: Most practices are matched with a qualified physician within 24 hours.
Practices with standardized documentation workflows are better positioned to maintain complete patient records, support clinical decision-making, and demonstrate physician oversight during compliance reviews.
Standardize Good Faith Exam Documentation Across Your Practice
Establish consistent physician oversight with a qualified medical director.
FAQ
What’s the fastest way to improve good faith exam charting?
Build a standardized EHR template using the SOAP format. A consistent template prompts providers to document the patient’s history, examination findings, assessment, and treatment plan during every encounter while reducing incomplete or inconsistent records.
Does a shorthand note ever count as sufficient charting?
A shorthand note that omits the patient’s history, clinical findings, assessment, or treatment plan does not meet the documentation standard. The medical record should explain why treatment was appropriate based on the provider’s evaluation.
How specific does the treatment plan section need to be?
The treatment plan should clearly document what was recommended, why the decision was made, any informed consent discussion, and the follow-up plan. Another provider reviewing the chart should be able to understand the clinical decision without additional explanation.
Should charting differ for a returning patient?
The SOAP structure remains the same for every encounter. Returning patient visits can reference relevant history from previous visits, but providers should still document the current evaluation, assessment, and treatment plan for that encounter.
Who’s responsible for making sure charting stays consistent across providers?
Responsibility typically falls to the supervising or collaborating physician together with the practice’s clinical leadership. Standardized EHR templates, written documentation policies, and regular chart reviews help maintain consistency across providers. Requirements for physician oversight vary by state.
Turn Good Faith Exam Charting Into a Standard Process
Charting a good faith exam correctly means documenting the encounter as a complete clinical evaluation instead of completing a checklist. A standardized SOAP note provides a consistent framework for documenting the patient’s history, clinical findings, assessment, and treatment plan. It also supports consistent physician oversight across the practice. Building that structure into your EHR helps providers document every good faith exam consistently.
Build a Stronger Good Faith Exam Process
Qualified medical directors for compliant physician oversight.
Bolton M. Harris, J.D., is a seasoned attorney with a formidable background in criminal law and a focus on healthcare law and compliance. As the in-house legal counsel at Medical Director Co., Harris brings a unique blend of prosecutorial experience and regulatory expertise to support healthcare professionals across Texas. Her career spans roles as a prosecutor in multiple counties and now as a trusted advisor on the legal intricacies of medical practice operations.
Education & Early Career
Bolton Harris completed her undergraduate studies at Southern Methodist University (SMU) in 2013. During her time at SMU, she was not only a dedicated student but also a competitive athlete on the university’s women’s swimming team. She went on to earn her Juris Doctor from Texas A&M University School of Law in 2016 and became a member of the Texas Bar that same year. Armed with a strong academic foundation and discipline honed as a student-athlete, Harris embarked on a career in criminal law immediately after law school.
Prosecutorial Experience in Texas
Bolton Harris began her legal career in public service as a criminal prosecutor. She served as an Assistant District Attorney in multiple jurisdictions, where she quickly rose through the ranks and handled a broad spectrum of cases. Some highlights of her prosecutorial career include:
- Assistant District Attorney, Dallas County, Texas: Prosecuted a high volume of criminal cases in one of the state’s busiest DA offices, gaining extensive trial experience in both misdemeanor and felony courts.
- Assistant District Attorney, Ellis County, Texas: Continued to hone her courtroom advocacy skills, known for meticulous case preparation and a tenacious pursuit of justice on behalf of the community.
- Assistant District Attorney, Navarro County, Texas: Broadened her legal expertise by handling diverse criminal matters in a smaller county, working closely with law enforcement and community leaders to uphold the law.
Through these roles, Harris built a reputation for being a tough but fair advocate. She brought numerous cases to trial and developed an in-depth understanding of the criminal justice system. This distinguished prosecutorial background laid a strong foundation for the next phase of her career in the private sector.
Healthcare Law & Compliance at Medical Director Co.
After her tenure as a prosecutor, Harris shifted her focus to healthcare law, applying her legal acumen to the medical field. She recognized that the same attention to detail and tenacity that served her in criminal law could benefit healthcare providers navigating complex regulations. Embracing this new direction, Harris became well-versed in the intricate laws governing medical practices – from licensing requirements to patient safety and privacy standards – and is passionate about helping practitioners stay compliant.
In her current role as the in-house attorney for Medical Director Co., Bolton Harris oversees all legal and compliance matters for the organization and its clients. Medical Director Co. is a nurse-owned firm that connects nurse practitioners (NPs), physician assistants (PAs), and registered nurses with qualified medical directors and collaborating physicians, offering fast placements and comprehensive compliance support for healthcare practices. Harris ensures that each of these partnerships and clinical ventures adheres to all applicable state and federal laws. She is responsible for drafting and reviewing collaborative practice agreements, advising on regulatory requirements, and providing ongoing legal counsel as clients establish and grow their clinics. Drawing on her prosecutorial eye for risk management, Harris proactively identifies potential legal issues and addresses them before they escalate, giving healthcare professionals peace of mind.
Bolton M. Harris’s multifaceted expertise – spanning high-stakes courtroom litigation to detailed healthcare compliance – makes her a formidable legal ally. Whether advocating in front of a jury or guiding a medical practice through regulatory hurdles, she remains committed to the highest standards of the legal profession. Her blend of courtroom-tested skill and healthcare law knowledge ensures that clients of Medical Director Co. receive elite-level counsel and steadfast protection in an ever-evolving legal landscape.
