A good faith exam process can fall out of compliance even when nothing appears wrong day to day. Providers change, new treatments are added, templates become outdated, and documentation habits can slip over time. A quarterly audit gives med spas a repeatable way to confirm that exams are still being performed by the right clinicians, completed before treatment, and documented consistently.
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 with the clinic you operate today, not the one you had when your GFE process was first created.
Good faith exam requirements can depend on the state, provider license, treatment, and how the evaluation is performed. That means a previously compliant workflow may need attention after the clinic changes.
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.
Do not assume that an unchanged form means the underlying requirements have also stayed unchanged.
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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 NP or 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
Policies cannot tell you whether staff are documenting exams correctly. Patient charts can.
Medical Director Co.’s current charting guidance recommends treating a GFE like a clinical encounter. The record should show the history, relevant findings, assessment, and treatment plan supporting the provider’s decision. A checklist alone should not replace the clinical note.
Select a reasonable sample of recent GFE records from different providers and treatment types.
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.
Medical Director Co.’s current documentation checklist recommends regular chart spot checks. Record reviews 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.
Medical Director Co.’s current guidance emphasizes that virtual GFEs should still function as real clinical evaluations. The process should not be reduced to a form, text exchange, or automated questionnaire.
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 whether 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.
Telehealth records may require additional details such as identity verification, telemedicine consent, and information about the virtual encounter.
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 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 whether 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, 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 |
Prioritize gaps that affect patient clearance, provider authority, treatment timing, or required physician involvement.
Then schedule a follow-up review.
Correcting the template is not enough if staff continue using the process incorrectly. The clinic should confirm that the change is actually reflected in new patient records.
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 whether 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
Medical Director Co. helps med spas maintain physician oversight as providers, services, and state requirements change.
Its medical director service can support GFE workflows, charting standards, standing orders, protocols, and ongoing clinical oversight. Medical Director Co.’s current documentation resources also recommend regular review of templates and charting practices rather than treating the GFE process as a one-time setup.
Current plans start at $799 per month, with qualified physician placement available within 24 hours.
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FAQs
How often should a med spa audit its good faith exam process?
A quarterly review provides a practical schedule for checking provider authority, documentation, workflows, and recent clinic changes. An additional review should occur sooner if the clinic adds services, providers, locations, or another state.
How many good faith exam charts should we review?
There is no single sample size that fits every practice. Choose enough recent charts to include different providers, treatment types, and both in-person and virtual exams if your clinic uses both formats.
What should a good faith exam documentation audit look for?
Review the patient’s relevant history, clinical findings, assessment, treatment plan, provider information, encounter date, and applicable consent. The record should show the clinical reasoning behind the treatment decision rather than only a completed checklist.
Should we audit telehealth GFEs separately?
Virtual workflows can introduce additional issues involving patient location, provider licensure, identity verification, telehealth consent, encounter format, and documentation. Review those elements in addition to the clinical content of the exam.
What is the biggest warning sign during a GFE audit?
A recurring gap across several charts is more concerning than one isolated documentation mistake. Examples include incomplete assessments, unsigned notes, missing provider credentials, or treatment occurring before documented clearance.
Does every state use the same good faith exam requirements?
Requirements can differ by state, treatment, provider license, and practice structure. Clinics operating in more than one state should review each jurisdiction separately.
Should the medical director participate in the audit?
The medical director should be involved when the audit touches clinical protocols, provider responsibilities, chart review, treatment authorization, or other physician oversight duties. Administrative staff can still handle operational parts of the review.
How does Medical Director Co. help with good faith exam compliance?
Medical Director Co. places qualified physicians and supports clinical oversight for med spas and other healthcare businesses. Its services can include agreements, standing orders, protocols, chart review, and ongoing compliance support.
Make the GFE Audit Part of Your Operating Routine
Good faith exam compliance should be checked against the way your clinic actually operates today. A quarterly audit can catch outdated workflows, documentation gaps, and provider changes before they become larger compliance problems.
Medical Director Co. can help maintain the physician oversight and clinical structure behind that process.
Keep your GFE process current.
Start with qualified 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.
