A good faith exam and informed consent serve different purposes, even though both take place before many prescription-based aesthetic treatments. A good faith exam determines whether the patient is an appropriate candidate for treatment. Informed consent explains the risks, benefits, and alternatives before the patient agrees to proceed. Because requirements vary by state, practices should also verify who can perform each step and how both should be documented.
Key Takeaways
- A qualified provider performs the good faith exam, while trained staff can often facilitate informed consent under the provider’s direction. (Jump to Section)
- The good faith exam documents a clinical decision, while informed consent documents the patient’s acknowledgment of risks and agreement to treatment. (Jump to Section)
- Both should be maintained in the patient’s medical record as separate documents. (Jump to Section)
- A signed consent form does not replace a documented good faith exam. (Jump to Section)
- Medical Director Co. helps med spas establish physician oversight and documentation processes that support both requirements. (Jump to Section)
Who Can Perform a Good Faith Exam vs. Informed Consent
The biggest difference between a good faith exam and informed consent is who is responsible for each process. A good faith exam is a clinical evaluation that should be performed by a qualified provider. Informed consent is part of the treatment process and can often be reviewed with the patient by trained staff under the provider’s direction. State laws determine who can perform each task.
Good Faith Exam | Informed Consent |
|---|---|
Performed by a qualified provider authorized under state law, such as an MD, DO, NP, or PA. | Often reviewed with the patient by trained clinical staff under the provider’s direction. |
Evaluates the patient’s medical history, clinical findings, and treatment eligibility. | Explains the proposed treatment, expected benefits, risks, alternatives, and recovery expectations. |
Establishes whether treatment is clinically appropriate. | Confirms the patient understands the information provided and agrees to proceed. |
Results in a documented clinical decision. | Results in a signed consent form that becomes part of the patient’s medical record. |
Although staff can help facilitate informed consent, the provider remains responsible for confirming the patient received adequate information before treatment. Physician oversight, delegation, and consent requirements vary by state.
What a Good Faith Exam and Informed Consent Document
A good faith exam documents the provider’s clinical evaluation and treatment decision. It supports the medical judgment behind the procedure. On the other hand, informed consent documents the patient’s understanding of the treatment, its risks, benefits, and alternatives before treatment begins. It confirms the patient agreed to proceed after receiving that information.
Good Faith Exam
A good faith exam documents the provider’s clinical evaluation before treatment is performed. The record should include:
- Patient history and relevant medical information.
- Clinical findings from the evaluation.
- Assessment of treatment eligibility.
- Treatment plan and supporting clinical documentation.
Together, these elements explain why the provider approved, modified, delayed, or declined treatment.
Informed Consent
An informed consent form documents the discussion that takes place before treatment begins. It confirms the patient received information about the proposed procedure and agreed to proceed. The record should include:
- The procedure being performed.
- Expected benefits and potential risks.
- Reasonable treatment alternatives.
- The patient’s opportunity to ask questions.
- The patient’s acknowledgment and signature before treatment.
Unlike a good faith exam, informed consent does not document the provider’s clinical evaluation. Both requirements serve different purposes and should be maintained as separate records.
Get Good Faith Exams and Informed Consent Right
Qualified medical directors with ongoing compliance support.
How to Document a Good Faith Exam and Informed Consent Separately
A good faith exam and informed consent should both be included in the patient’s medical record, but they should be documented as separate entries. Keeping them separate makes it easier to verify that each requirement was completed and prevents one document from being mistaken for the other.
A complete patient record should include:
- Good faith exam: The provider’s evaluation, clinical findings, assessment, and treatment plan.
- Informed consent: The signed consent form documenting the patient’s acknowledgment of the treatment, risks, benefits, and alternatives.
- Supporting documentation: Clinical photographs, treatment records, or other documents maintained as part of the patient’s chart, when appropriate.
- Provider documentation: Signatures, dates, and other required records that support physician oversight and patient care.
Clear labeling within the EHR also improves documentation. Practices often maintain separate sections for the good faith exam, informed consent, treatment notes, and follow-up visits so each record can be reviewed independently.
Documentation requirements, renewal frequency, and telehealth rules vary by state. Practices should confirm that their documentation process aligns with applicable state laws.
How Medical Director Co. Helps Practices Get Both Right
Medical Director Co. helps med spas establish physician oversight and documentation processes that support good faith exams and informed consent.
Services include:
- Qualified medical directors: Physicians experienced in med spa oversight and state-specific compliance requirements.
- Attorney-reviewed agreements: Documentation that supports compliant physician relationships.
- Ongoing compliance support: Guidance as regulations, treatment offerings, and documentation requirements evolve.
- Fast physician placement: Most practices are matched with a qualified physician within 24 hours.
Standardized physician oversight helps practices document good faith exams, informed consent, and treatment records consistently across every provider and location.
Build a Consistent Good Faith Exam Process
Qualified medical directors with ongoing compliance support.
FAQ
Can front desk staff handle informed consent?
Trained staff can review a consent form with the patient and answer general questions under the provider’s direction. The provider remains responsible for confirming the patient received adequate information and understood the proposed treatment before proceeding. State requirements vary.
Does informed consent need to reference the exam findings?
The informed consent discussion should reflect the treatment plan developed during the good faith exam. Although the documents are maintained separately, they should be consistent with the provider’s clinical evaluation and treatment recommendation.
Is one requirement more heavily enforced than the other?
Both are important, but regulators often begin by determining whether a valid provider-patient relationship and clinical evaluation existed before treatment. A signed consent form does not replace a properly documented good faith exam.
Do both need to be repeated at every visit?
That depends on state requirements and the treatment being performed. Good faith exams are often renewed periodically, while informed consent is generally updated when the treatment plan changes or new risks should be disclosed.
What’s the clearest way to tell them apart in practice?
A good faith exam answers whether the patient is an appropriate candidate for treatment. Informed consent confirms the patient understands the proposed treatment, its risks, available alternatives, and agrees to proceed. They should always be documented separately.
Keep Good Faith Exams and Informed Consent Separate
A good faith exam and informed consent work together, but they are not interchangeable. One documents the provider’s clinical decision, while the other documents the patient’s informed agreement to treatment. Maintaining both as separate records helps support consistent documentation, physician oversight, and state-specific compliance.
Strengthen Your 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.
