A good faith exam (GFE) note should tell another clinician what the patient came in for, what the evaluating provider found, and why treatment was approved, modified, or declined. A completed form with a signature and a simple “cleared for treatment” statement may leave important clinical questions unanswered.
For med spas offering injectables, IV hydration, and other medical treatments, proper charting is part of responsible patient care. It also helps establish that an appropriate evaluation took place before treatment when required. The Subjective, Objective, Assessment, and Plan (SOAP) format provides a practical way to organize these records, although it is not a universally mandated GFE format.
This guide explains what belongs in each section, how to document treatment decisions, and how to build an electronic health record (EHR) template that clinicians can use consistently.
Key Takeaways
- A SOAP note provides a practical structure for documenting a good faith exam, including the patient’s history, clinical findings, assessment, and plan. (Jump to Section)
- The assessment and plan should explain the treatment decision, not simply state that a patient was cleared. (Jump to Section)
- A useful GFE template includes relevant patient information, provider identification, treatment authorization, and appropriate follow-up documentation. (Jump to Section)
- Standardized templates should support individual clinical judgment, not encourage identical notes across different patients. (Jump to Section)
- Medical Director Co. helps med spas establish physician oversight arrangements that support appropriate clinical documentation practices. (Jump to Section)
Structuring a Good Faith Exam Note
A good faith exam is a clinical evaluation used to determine whether a patient is suitable for a proposed treatment. The term is common in medical aesthetics, although states may use different terminology for the required medical assessment.
SOAP notes are useful because they separate information reported by the patient from the provider’s observations, conclusions, and treatment decisions.
The four sections are:
Subjective (S): What the patient reports.
Objective (O): What the evaluating clinician observes or measures.
Assessment (A): What the clinical findings mean.
Plan (P): What treatment or next steps are recommended.
The Centers for Medicare & Medicaid Services (CMS) emphasizes that patient encounters should be documented completely, accurately, and on time. The amount of detail needed depends on the clinical circumstances and applicable requirements.
Subjective (S)
Start with the patient’s reason for seeking treatment and the medical information relevant to the planned procedure.
For an injectable treatment, this may include previous aesthetic procedures, current medications, allergies, and medical conditions that could affect treatment suitability.
Document:
Chief concern: The treatment requested and the patient’s primary concern.
Medical history: Relevant diagnoses, past procedures, and prior complications.
Current medications: Prescription drugs, over-the-counter medications, and supplements relevant to care.
Allergies: Known allergies and significant previous reactions.
Treatment history: Previous experiences with the same or similar procedures.
Patient goals: The patient’s expectations and concerns about the proposed treatment.
For example, a patient returning for Botox may report starting a new medication since the previous visit. That change deserves attention even if earlier treatments were uneventful.
Avoid carrying forward outdated history without confirming that the information remains accurate.
Objective (O)
The objective section records findings from the clinician’s examination and other relevant clinical information.
For aesthetic procedures, this may include the condition of the treatment area, visible skin changes, relevant anatomy, and other findings needed to assess safety.
Depending on the treatment, document:
Relevant physical examination findings.
Signs of infection, irritation, inflammation, or injury.
Appropriate vital signs or clinical measurements.
Relevant laboratory or diagnostic findings when indicated.
Clinical photographs when appropriate and obtained under applicable consent and privacy procedures.
An objective entry should be specific enough to explain what was evaluated.
For example, “skin normal” may provide little useful information if the intended procedure requires assessment of a particular treatment area.
The scope of the examination should match the proposed treatment. An injectable consultation and an IV hydration evaluation may require different findings.
Standardize Good Faith Exam Documentation
A consistent charting process helps clinicians capture the information needed for treatment decisions without relying on memory alone. Medical Director Co. connects clinics with qualified physicians who can support appropriate clinical oversight arrangements.
Where Clinical Documentation Matters Most
The assessment and plan are especially important because they explain what the evaluating clinician decided after reviewing the history and examination findings.
A chart may contain several pages of patient information but still be incomplete if it never explains the reason for approving or declining treatment.
Assessment (A)
The assessment records the clinician’s interpretation of the information collected during the evaluation.
It should explain whether the patient is an appropriate candidate for the proposed procedure and identify findings that affect that decision.
Include:
Clinical impression: The relevant conclusion from the evaluation.
Treatment suitability: Whether the proposed treatment is appropriate.
Contraindications and precautions: Any factors requiring caution or additional evaluation.
Clinical reasoning: Why the clinician approved, modified, postponed, or declined treatment.
Avoid relying on phrases such as “GFE passed” or “patient approved” without supporting clinical information.
A more informative assessment describes the relevant findings and explains the treatment decision.
For example, if a patient presents with an active infection near the proposed injection site, the assessment should address that finding and explain why treatment is being deferred.
Plan (P)
The plan records what happens after the assessment.
If treatment is appropriate, the note should identify the proposed procedure and relevant clinical instructions. If treatment is postponed, the plan should explain what additional steps are needed.
Document, as applicable:
Treatment decision: The specific procedure recommended, authorized, deferred, or declined.
Treatment details: Relevant medications, procedures, or treatment parameters when appropriate.
Patient education: Risks, benefits, alternatives, and expectations discussed.
Consent: Documentation of the applicable informed consent process.
Follow-up: Recommended monitoring, reassessment, or subsequent appointments.
Referral or additional testing: Further evaluation needed before proceeding.
Informed consent and the clinical assessment serve different purposes. Consent establishes the patient’s informed decision to proceed, while the assessment explains the provider’s determination of medical suitability.
A signed consent form does not replace an appropriate medical evaluation.
Example of a Good Faith Exam Chart
The following is a simplified educational example involving a patient who requests cosmetic injection treatment but has a clinical finding that warrants postponement.
| SOAP Section | Example Documentation |
|---|---|
| Subjective | Patient requests cosmetic injection treatment. Reports recent irritation near the proposed treatment area. Medication and allergy histories reviewed. |
| Objective | Localized redness and irritation observed at the proposed treatment site. Additional examination findings documented as applicable. |
| Assessment | Treatment deferred because the current skin findings require further assessment or resolution before proceeding. |
| Plan | Do not proceed with the injection today. Provide appropriate clinical instructions and arrange reassessment before treatment is reconsidered. |
Illustrative example only. This is not a complete patient record or a treatment protocol.
A real chart should contain additional information appropriate to the patient, procedure, and jurisdiction, including the evaluating clinician’s identity, encounter details, and authenticated documentation.
The example shows why the assessment and plan matter. Another clinician reviewing the note can understand why the requested procedure did not go ahead.
Building a Standard Good Faith Exam Template
A well-designed EHR template can make charting easier without reducing the evaluation to a series of checkboxes.
The goal is to give providers a consistent place to document the information they need while allowing room for patient-specific findings.
A useful GFE template should include:
Patient identification and encounter date.
Evaluating clinician’s name and credentials.
Requested treatment or reason for evaluation.
Relevant medical history and current medications.
Appropriate physical examination findings.
Clinical assessment and treatment decision.
Treatment plan and applicable consent documentation.
Follow-up or referral instructions.
Provider authentication and relevant encounter timestamps.
For clinics using telehealth, additional documentation may be necessary. These requirements are covered in our virtual good faith exam guide.
Common Charting Mistakes to Avoid
Templates save time, but they can also create documentation problems when staff rely too heavily on prefilled information.
Watch for the following issues.
Copying Previous Assessments
A prior evaluation may contain useful history, but the current note must reflect the patient’s present condition and the clinical decision being made.
Using the Same Findings for Every Patient
Identical entries across multiple records may suggest that examination details are being copied instead of documented individually.
Recording Approval Without Clinical Reasoning
A treatment authorization should be supported by the findings relevant to that decision.
Leaving Provider Information Incomplete
Records should identify the clinician responsible for the evaluation and include appropriate authentication.
Failing to Document a Change in Treatment
If the patient changes procedures or develops a new clinical concern, the provider should determine whether another evaluation is needed and document that decision.
Confusing the Evaluation With the Procedure Note
A GFE documents the assessment and decision about treatment. The procedure record documents what was actually administered or performed. Some information may overlap, but one should not automatically substitute for the other.
Make the Template Useful for Your Treatment Menu
A med spa offering several services may need different assessment prompts for injectables, IV therapy, laser procedures, or prescription weight management.
For example, the assessment relevant to an injectable procedure may not capture everything needed before an IV infusion.
Keep the core patient information consistent, but include treatment-specific fields where they support appropriate clinical evaluation.
The template should also allow clinicians to record when a procedure is declined, deferred, or referred for additional assessment.
Keep Chart Corrections Traceable
If a note needs correction after it has been completed, follow the EHR’s amendment process and applicable recordkeeping requirements.
Do not silently replace the original entry or backdate an examination. Corrections should remain attributable to the person making them, with the appropriate date and time.
For a concrete state example, Texas Administrative Code Section 163.1 addresses contemporaneous documentation, medical record corrections, and identification of the person making an amendment.
These are Texas-specific provisions, not universal rules for every med spa. Clinics must follow the requirements governing their own practice.
How Medical Director Co. Supports Consistent Good Faith Exam Charting
Good faith exam documentation is ultimately the responsibility of the clinician performing the evaluation. Still, practices need clear procedures for who may evaluate patients, how decisions are recorded, and when physician consultation is required.
Medical Director Co. helps medical spas establish physician relationships appropriate to their services and state requirements.
Depending on the arrangement, physician oversight may support:
Clinical Protocols: Establishing expectations for patient evaluations and treatment authorization.
Provider Responsibilities: Clarifying which clinicians may perform evaluations and which treatments require additional physician involvement.
Documentation Procedures: Supporting appropriate charting expectations and clinical communication.
Quality Assurance: Participating in clinical review activities when required or agreed upon.
A medical director can help a practice establish consistent procedures, but physician oversight does not automatically make an incomplete note compliant.
The record must accurately reflect the care provided and the clinical decision made.
Need Physician Oversight for Your Med Spa?
If your clinic needs a qualified medical director or help establishing an appropriate physician relationship, Medical Director Co. can discuss your services and oversight requirements.
FAQ
What Is the Best Format for Documenting a Good Faith Exam?
The SOAP format is a practical option because it organizes the patient’s history, examination findings, clinical assessment, and treatment plan. However, no single SOAP template is universally required for every med spa. Documentation must meet applicable state requirements and accurately reflect the clinical evaluation.
Is a Checklist Enough for Good Faith Exam Documentation?
A checklist can support the assessment, but it may not be sufficient on its own. The clinical record should contain enough information to explain the patient’s condition, relevant findings, and the provider’s treatment decision.
Does a Good Faith Exam Note Need a Provider Signature?
Medical records should be appropriately authenticated by the responsible clinician under applicable requirements. Electronic authentication may satisfy this obligation when permitted. Clinics should follow their state’s rules and maintain reliable identification of the provider completing the note.
Should Charting Differ for Returning Patients?
The documentation should reflect the current encounter. A returning patient’s previous history may remain relevant, but providers need to consider changes in health, medications, or the planned procedure. Whether a new evaluation is required depends on the circumstances and applicable state law.
Can a Nurse Practitioner or Physician Assistant Complete the GFE Note?
Yes, when the clinician is legally authorized to perform the underlying evaluation. The provider’s professional scope, prescribing authority, and any applicable collaboration or supervision requirements determine whether they may independently assess and authorize treatment.
How Often Should a Med Spa Review Its GFE Documentation?
Regular spot checks can identify incomplete assessments, missing signatures, or inconsistent charting practices. The appropriate schedule depends on applicable requirements and the clinic’s operations. For a practical review process, see our quarterly GFE audit checklist.
Turn Good Faith Exam Charting Into a Standard Process
A good faith exam record should make the treatment decision understandable. Anyone reviewing the chart should be able to identify what the patient reported, what the clinician found, and why the proposed treatment was approved, changed, or postponed.
The SOAP format provides a straightforward way to organize that information. A well-designed EHR template can make the process more consistent, provided clinicians still document each patient’s individual findings.
If your practice needs appropriate physician oversight to support its clinical operations, Medical Director Co. can help you explore a physician arrangement that fits your services and state requirements.
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.
