A signed waiver or completed intake checklist won’t defend a chart when a state board or malpractice insurer reviews it. Reviewers look for a clinical record that shows who evaluated the patient, what they found, and why they approved, modified, or deferred treatment. Good faith exam documentation that answers those three questions holds up, whether the exam happened in person or by telehealth.
Key Takeaways
- Chart every good faith exam as a full SOAP note, the same format used for any other patient encounter. (Jump to Section)
- A checklist or waiver can’t show the clinical reasoning behind a treatment decision, so it can’t replace the note. (Jump to Section)
- The record also needs informed consent, the provider’s signature and credentials, treatment orders, and follow-up instructions. (Jump to Section)
- Telehealth exams follow the same standard, with the visit type, identity check, and any required telehealth consent added to the chart. (Jump to Section)
Good Faith Exam Documentation Follows the SOAP Format
A good faith exam doesn’t need its own charting format, and the note should meet the same standard as any other patient evaluation. CMS’s general documentation principles require complete, legible records that identify the provider and the date of service. A SOAP note covers those basics and gives a reviewer the clinical story in the order they expect to read it.
Subjective: The reason for the visit, medical history, current medications, allergies, and prior treatments that affect candidacy.
Objective: Exam findings for the treatment area, vital signs when relevant, and baseline photos or labs when they inform the plan.
Assessment: The provider’s clinical impression, any contraindications, and a clear statement on whether the patient is a candidate.
Plan: The treatment ordered, risks and benefits discussed, consent obtained, patient education, and follow-up.
Building these four headings into an EHR template is the simplest way to chart a good faith exam correctly on every patient.
Why a Checklist Alone Fails a Chart Review
Checklists help providers cover the same ground with every patient, and that consistency is worth keeping. Trouble starts when the checklist becomes your entire good faith exam documentation, because a column of checked boxes can’t explain why treatment was approved. ProAssurance, a medical malpractice insurer, makes a similar point about consent forms: a signature doesn’t replace a chart entry that summarizes the actual discussion.
| What a reviewer looks for | Checklist only | Complete good faith exam record |
|---|---|---|
| Medical history | Yes/no boxes | Conditions, medications, and allergies tied to the decision |
| Exam findings | “Exam completed” | Findings for the treatment area |
| Clinical decision | Usually missing | Candidacy, contraindications, and reasoning |
| Treatment plan | Service name only | Order, education, and follow-up |
| Provider identity | Initials or blank | Signature and credentials |
Two habits cause many of the gaps in that table. The first is letting a sales consultation stand in for the good faith exam, which leaves a chart with goals and pricing and no clinical decision. The second is a template that only asks for checkmarks, a problem EMR software built for med spas avoids by prompting the provider for findings and reasoning.
What Else Belongs in the Patient Record
The exam note sits at the center of good faith exam documentation, and reviewers check the documents around it next. In California, Business and Professions Code section 2242 makes it unprofessional conduct to prescribe dangerous drugs without an appropriate prior examination and a medical indication. Supporting documents are how a clinic shows both conditions were met for each patient.
Informed consent: The AMA Code of Medical Ethics asks physicians to document the consent conversation and the patient’s decision, and to keep any signed consent form in the record.
Provider signature and credentials: The provider who performed the exam signs the note with the credentials state law requires. When an NP or PA performs the exam under delegation, the chart should also reflect the medical director’s oversight of the good faith exam.
Treatment orders: Each order should trace back to the assessment that justified it.
Photos and diagnostics: Pre-treatment photos or lab results set a clinical baseline when they’re relevant to the plan.
Follow-up instructions: Aftercare, warning signs to watch for, and the next scheduled evaluation.
Charts That Hold Up
Physician oversight with attorney-reviewed agreements.
Telehealth Good Faith Exams Meet the Same Standard
A virtual visit doesn’t lower the bar for good faith exam documentation. The Federation of State Medical Boards’ telemedicine policy holds virtual care to the same standard as an in-person visit and says telemedicine isn’t appropriate when that standard can’t be met remotely. Some states add their own steps, and California’s telehealth consent rule requires the provider to document the patient’s consent to telehealth in the medical record.
Alongside the full SOAP note, a telehealth good faith exam record should show:
Encounter details: The date, time, and whether the visit was live video, audio, or asynchronous.
Identity verification: How the provider confirmed the patient’s identity before the evaluation.
Telehealth consent: The patient’s verbal or written consent to telehealth, where the state requires it.
Clinical reasoning: How the provider reached the treatment decision from what they could assess remotely.
State rules on telemedicine clearance for good faith exams keep changing, so confirm your state’s current requirements before you adjust your workflow.
How Medical Director Co. Builds Documentation Into Every Placement
Good faith exam documentation stays consistent when the overseeing physician knows your state’s rules and reviews charts on a set schedule. Medical Director Co. matches med spas and other clinics with a qualified physician licensed in their state within 24 hours. Our in-house healthcare attorney, Bolton Harris, J.D., reviews each physician agreement and its state-specific documentation before it reaches your practice. You also get ongoing compliance support as documentation standards and state rules change.
Oversight Built Into Charting
Attorney-reviewed agreements and ongoing compliance support.
Frequently Asked Questions
Is there a special template for good faith exam documentation?
Good faith exams use the same SOAP note structure as any other patient encounter. A practice template can add fields for candidacy, contraindications, and photos, as long as the provider still writes the findings and reasoning. Templates should prompt clinical thinking instead of replacing it with checkboxes.
What makes a good faith exam note insufficient?
A good faith exam note falls short when it’s missing the history, exam findings, assessment, or treatment plan. Reviewers also flag notes that don’t name the provider or link the order to a clinical decision. A waiver or intake form on its own doesn’t explain why treatment was approved.
Can a patient questionnaire replace the good faith exam?
A questionnaire supports the good faith exam, while the provider’s review and decision complete it. California’s section 2242 allows an appropriate exam to include telehealth tools such as a self-screening questionnaire, and other states set different rules. Whatever the format, the chart has to show that a qualified provider reviewed the answers and made the call.
Does telehealth documentation follow a lower standard?
Telehealth good faith exams follow the same documentation standard as in-person visits. The record still needs the assessment, treatment decision, consent, and any orders issued. Add the encounter type, identity verification, and any telehealth consent your state requires.
Does informed consent need to be in the good faith exam record?
Informed consent documentation belongs in the same record as the exam note, the order, and the provider’s signature. Document the conversation itself, including the risks, benefits, and alternatives discussed. Attach the signed form, but don’t let it stand in for the note.
How often should a good faith exam be repeated?
Timing depends on state rules and your clinic’s protocols. The American Med Spa Association recommends a new exam for treatments outside the original plan or after a significant health change, and at least once a year as a rule of thumb. Chart each repeat exam as its own complete encounter.
Who reviews good faith exam documentation during an audit?
State medical and nursing boards review charts during investigations, and malpractice insurers review them when evaluating claims. Both want to see that a qualified provider evaluated the patient before treatment began.
Getting Your Good Faith Exam Charts Audit-Ready
A good faith exam record holds up when it reads like a real clinical evaluation, with a complete SOAP note, documented consent, and a signed order tied to the assessment. Pull five recent charts and check each one against the table above. Any chart with a checked box where reasoning should be is where your fixes start.
Matched in 24 Hours
Qualified physician oversight for every good faith exam.
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.
