A good faith exam (GFE) may be documented correctly when a med spa first opens, but what happens six months later? A new injector joins the team, the clinic introduces another treatment, or staff begin using an outdated patient form. Small changes like these can create gaps that go unnoticed until someone reviews the records.
A quarterly GFE audit helps med spas catch those problems early. Medical Director Co. recommends reviewing provider credentials, actual patient charts, treatment timing, and clinical protocols to check that the process still meets applicable requirements. The checklist below covers seven areas worth examining every three months, along with a simple scorecard to document your findings.
Key Takeaways
- Start each quarterly review by confirming that your current providers and services still match applicable state requirements. (Jump to Section)
- A chart audit should test actual patient records rather than relying on policies or blank templates. (Jump to Section)
- Telehealth exams need their own review because provider location, patient location, consent, and documentation can create additional gaps. (Jump to Section)
- New services, providers, medications, or locations should trigger an additional compliance review between quarterly audits. (Jump to Section)
- Every audit should end with documented corrective actions and a date for follow-up. (Jump to Section)
1. Confirm the Rules Still Match Your Current Practice
Start by looking at how your clinic operates today. The good faith exam process you established when you opened may no longer cover every provider, treatment, or location.
Requirements differ across states. Some regulations address medical evaluations, physician delegation, or prescribing authority without using the term good faith exam. During your quarterly review, check the rules that apply to your services and confirm that your written policies reflect them.
During the quarterly review, confirm:
Current state requirements: Verify that your process still reflects the rules and board guidance that apply where patients are treated.
Provider authority: Confirm that the clinician performing each exam is authorized to evaluate the patient and approve the treatment.
Service coverage: Make sure your GFE process addresses every treatment that currently requires an evaluation before care.
Renewal requirements: Check whether your policy accurately reflects when another exam is needed.
Physician involvement: Confirm that the medical director or supervising physician is performing any responsibilities required by the clinic’s current structure.
An outdated form is usually easy to spot. A process that no longer matches the clinic’s clinical responsibilities may be harder to catch, which is why this review matters.
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2. Verify Who Is Performing the Exams
The next step is confirming that the people performing GFEs are the same people your policies say should be performing them.
Staffing changes can quietly create compliance gaps. A provider may leave, a new nurse practitioner (NP) or physician assistant (PA) may start, or a clinic may begin relying on a different telehealth clinician without updating its workflow.
Check:
Active licensure: Verify that each evaluating provider holds the required active license.
State authorization: For multi-state or telehealth practices, confirm that the provider is authorized in the patient’s state.
Role alignment: Make sure the provider’s actual responsibilities match the collaborative, supervisory, delegation, or medical director structure in place.
Credentials in the chart: Patient records should clearly identify who performed the exam and the provider’s professional credentials.
Coverage arrangements: Confirm who performs GFEs when the primary clinician is unavailable.
The audit should leave no uncertainty about who is authorized to clear patients for treatment.
3. Audit a Sample of Good Faith Exam Charts
A clinic can have a well-written GFE policy and still end up with incomplete patient records. The only way to find out how consistently staff follow the process is to review actual charts.
Start with a sample of recent evaluations. Include different providers, treatment types, and both in-person and virtual exams if your clinic offers them. For example, a practice might review 10 to 20 charts as an initial internal spot check, then increase the sample if it finds recurring problems. This is a practical starting point, not a state-mandated number.
Pay particular attention to charts completed after a staffing change, the introduction of a new treatment, or an update to your documentation system. These records may reveal problems that routine reviews have missed.
For each chart, confirm that it includes:
Relevant patient history: The record should capture information such as medical conditions, medications, allergies, and other details relevant to treatment.
Clinical findings: The note should include the findings the provider used when evaluating treatment suitability.
Assessment: The provider should document the clinical conclusion rather than only recording that the patient “passed” or was “cleared.”
Specific treatment plan: The chart should connect the evaluation to the treatment being considered.
Provider identification: The evaluating clinician’s name and credentials should be clear.
Date of the encounter: The record should establish that the evaluation occurred before treatment.
Required consent: Confirm that the applicable consent documentation is present and complete.
Regular chart spot checks can uncover missing signatures, credentials, timing issues, or gaps in clinical reasoning that policy reviews may miss.
Watch for Repeated Documentation Patterns
Several charts with identical language can indicate that templates are being copied without enough patient-specific detail. Audit for quality, not just presence.
Look for:
Identical assessments across patients;
Missing individualized findings;
Blank required fields;
Copied medication lists;
Treatment plans that do not match the service provided; and
Unsigned or incomplete notes.
Templates should improve consistency. They should not replace clinical judgment.
4. Review Your Telehealth Good Faith Exam Workflow
Virtual exams deserve a separate audit because the workflow includes details that may not exist in an in-person encounter.
A virtual GFE should still function as a clinical evaluation. The process should not be reduced to a form, text exchange, or automated questionnaire when a clinician-performed assessment is required.
For telehealth exams, verify:
Patient location: Staff document where the patient is physically located during the evaluation.
Provider authority: The clinician is licensed or otherwise authorized to practice in the patient’s state.
Identity verification: The workflow includes a method for confirming the patient’s identity when required.
Telehealth consent: Appropriate consent for the virtual encounter is documented.
Clinical evaluation: The provider performs an actual assessment rather than relying only on information submitted before the call.
Treatment decision: The chart clearly records if treatment was approved, declined, or deferred.
Encounter format: The record reflects how the virtual evaluation occurred when applicable.
Secure technology: The clinic uses technology that fits its privacy and security obligations.
For clinics using physicians or other evaluating providers based outside the patient’s state, confirm that the clinician has the necessary authorization where the patient is physically located during the appointment.
The U.S. Department of Health and Human Services (HHS) explains that interstate telehealth practice may require additional licensing or authorization. The clinic should also review the security of its telehealth platform and how staff verify patient identity and document consent.
Using Virtual Good Faith Exams?
Make sure the workflow matches your state and providers.
5. Confirm the Exam Happens Before Treatment
A complete GFE performed at the wrong point in the patient journey can still create a problem. Your audit should confirm that the required evaluation happens before the treatment it is intended to authorize.
Compare:
GFE date and time;
Treatment date and time;
Provider approval;
Prescription or treatment order, when applicable; and
Any required consent documentation.
Then look at the actual scheduling workflow.
Ask:
Can staff schedule treatment before the GFE is complete?
Can a provider administer treatment if the exam is still pending?
Does the electronic health record (EHR) or scheduling system clearly show clearance status?
What happens if the patient changes treatments after the original exam?
A strong process prevents treatment from moving forward until the required evaluation is complete.
6. Check for Changes Since the Last Audit
Quarterly audits are useful because clinics rarely stay exactly the same for long. A change in the practice can affect the GFE workflow even when no one intentionally changed the policy.
Review if the clinic has:
Added a treatment: New injectables, IV therapies, prescription weight management, hormone services, or other treatments may require a different evaluation process.
Added a medication: The provider may need to evaluate different contraindications, risks, or prescribing requirements.
Hired another provider: A new NP, PA, registered nurse (RN), or physician can change who performs the GFE or how oversight is structured.
Changed medical directors: Agreements, standing orders, protocols, and communication processes may need to be updated.
Opened another location: Another site may create new staffing or state-specific requirements.
Expanded into another state: Do not assume the original state’s GFE workflow applies in the new jurisdiction.
Changed telehealth systems: Make sure the new platform still supports your documentation, privacy, identity, and consent workflow.
Any significant change should trigger a review when it happens. Do not wait for the next scheduled quarterly audit if the clinic’s clinical model has already changed.
7. Document and Correct the Gaps You Find
Create a short audit record that identifies what was reviewed, what was missing, who is responsible for correcting it, and when the correction should be complete.
A simple corrective-action log can include:
| Finding | Action Needed | Owner | Due Date | Follow-Up |
|---|---|---|---|---|
| Missing provider credentials in GFE notes | Update EHR template | Practice manager | Set date | Recheck sample |
| Telehealth patient location not documented | Add required field | Clinical lead | Set date | Audit new charts |
| New IV service not reflected in workflow | Review GFE and standing orders | Medical director | Set date | Confirm approval |
| Inconsistent chart signatures | Retrain providers | Office manager | Set date | Spot-check charts |
Not every finding requires the same response. A missing signature may be resolved through staff follow-up, while a treatment performed without a required evaluation needs prompt clinical and compliance review.
Give each finding an owner and a deadline. Once a correction is made, check a few new records to see if the change is working. For example, if staff were forgetting to record the patient’s location during virtual exams, review subsequent telehealth charts after updating the template.
Keep the audit results and follow-up records together. When the next quarterly review comes around, you’ll be able to see which problems were resolved and which ones continue to appear.
A Simple Quarterly Good Faith Exam Audit Scorecard
Use the same categories each quarter so you can compare results over time.
| Audit Area | Pass | Needs Review |
|---|---|---|
| State requirements reviewed | ☐ | ☐ |
| All GFE providers properly authorized | ☐ | ☐ |
| Provider licenses current | ☐ | ☐ |
| GFE template reflects current services | ☐ | ☐ |
| Sample charts contain complete clinical documentation | ☐ | ☐ |
| Treatment decision clearly documented | ☐ | ☐ |
| GFE occurs before treatment | ☐ | ☐ |
| Provider credentials and signatures present | ☐ | ☐ |
| Telehealth workflow reviewed | ☐ | ☐ |
| New services and providers incorporated | ☐ | ☐ |
| Medical director responsibilities current | ☐ | ☐ |
| Corrective actions from previous audit completed | ☐ | ☐ |
A failed item does not automatically mean the entire GFE program is noncompliant. It means the clinic has identified an area that needs review before it becomes a larger problem.
Who Should Participate in the Quarterly Review?
The audit should involve the people who actually control the workflow. Depending on the clinic, that may include:
Practice or office manager: Reviews scheduling, forms, staff processes, and completion rates.
Clinical lead: Checks if clinicians are following the required exam and documentation process.
Medical director: Reviews clinical standards, provider responsibilities, treatment protocols, and physician oversight expectations.
Compliance or legal support: Helps address state-specific regulatory questions when needed.
The audit does not need to become a large committee meeting. The goal is to make sure operational, clinical, and oversight responsibilities are all represented.
How Medical Director Co. Supports Ongoing GFE Compliance
A quarterly audit may reveal issues that administrative staff cannot resolve alone. Questions about provider authority, clinical protocols, or physician responsibilities may need input from a medical director.
Medical Director Co. connects med spas with qualified physicians who can provide clinical oversight appropriate to their services. Depending on the arrangement, that support may include reviewing protocols, establishing standing orders, and addressing documentation or clinical workflow concerns.
Plans start at $799 per month, with physician matching targeted within 24 hours, subject to availability.
Need Physician Support for Your GFE Process?
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FAQs
How Often Should a Med Spa Audit Its Good Faith Exam Process?
A quarterly review is a practical starting point for most clinics. You should also review the process when introducing new treatments, hiring providers, changing medical directors, or expanding into another state. Quarterly audits are a recommended internal practice, not a universal legal requirement.
How Many Good Faith Exam Charts Should We Review?
There is no single sample size suitable for every med spa. Smaller clinics might begin with 10 to 20 recent records, while larger practices may need broader sampling. Include different providers and treatments, and review more charts if you discover repeated documentation problems.
What Is the Most Serious Issue a GFE Audit Might Uncover?
One important concern is treatment occurring before a required medical evaluation or authorization. Other findings that may need prompt attention include evaluations performed by unauthorized providers, incomplete clinical assessments, and missing treatment decisions.
Should Virtual Good Faith Exams Be Audited Separately?
Yes. Along with checking the clinical assessment, review patient location, provider authorization, telehealth consent, identity verification, and the documentation of the virtual encounter. These additional steps can reveal problems that would not arise during an in-person visit.
Who Should Be Responsible for Correcting Audit Findings?
The responsibility depends on the issue. Practice managers may address scheduling and documentation workflows, while clinical leads and medical directors should handle concerns involving clinical protocols, provider authority, or patient care. Every corrective action should have a named owner and follow-up date.
Make the GFE Audit Part of Your Operating Routine
A quarterly review gives your clinic an opportunity to catch small problems before they affect patient care or create larger compliance concerns. Keep the process manageable: review the records, document what needs attention, assign responsibilities, and check that corrections have been completed.
If your audit raises questions about physician oversight or clinical responsibilities, Medical Director Co. can help you find qualified medical director support for your practice.
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.
