What happens after the Good Faith Exam?

If the patient is approved, the treatment plan is documented, and they may proceed with scheduling. If not, they must be deferred with documentation and explanation.

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Good Faith Exam Documentation: Best Practices for Med Spas

In the evolving landscape of aesthetic medicine, med spas are rapidly expanding their treatment menus and patient offerings. Yet with this growth comes an increased need for regulatory vigilance. One of the most critical areas of compliance is the Good Faith Exam. This foundational assessment isn’t just a legal formality, it’s the linchpin of ethical, compliant care in medical aesthetics.

This article explores Good Faith Exam documentation best practices for med spas, ensuring you stay compliant while optimizing workflow and enhancing patient trust.

What Is a Good Faith Exam?

A Good Faith Exam (GFE) is a medical evaluation performed by a qualified healthcare provider to determine whether a patient is an appropriate candidate for a medical treatment or procedure. For med spas, this typically precedes procedures involving prescription-strength devices, medications, or injectables such as Botox, dermal fillers, hormone therapies, or GLP-1s for weight management.

A GFE is not optional. It is required by state medical boards and often enforced under telemedicine and scope-of-practice laws. Failing to perform or document a Good Faith Exam can lead to severe penalties, including fines, loss of licensure, or legal action.

Learn more about Good Faith Exam requirements by state through the Federation of State Medical Boards.

Why Good Faith Exam Documentation Matters

Documenting a Good Faith Exam is not just about ticking a box. Proper documentation:

Demonstrates medical necessity
Protects providers in case of liability claims
Ensures continuity of care
Aligns with state and federal telehealth regulations
Enhances the patient experience by conveying professionalism

Given how many aesthetic practices now use telehealth platforms to conduct GFEs virtually, the importance of standardized documentation has grown exponentially.

Elements of a Proper Good Faith Exam

A legally sound Good Faith Exam should include the following elements:

1. Medical History Review

The provider must review the patient’s current and past medical history, including allergies, medications, contraindications, and previous aesthetic or medical treatments.

2. Physical or Visual Examination

Even in virtual consultations, a visual inspection of the treatment area is essential. This may involve live video or asynchronous photo documentation, depending on state law.

3. Assessment and Diagnosis

The provider must make a preliminary diagnosis based on the findings and determine whether the patient is a suitable candidate for the requested procedure or prescription.

4. Informed Consent

Patients must be fully informed of the treatment’s risks, benefits, and alternatives, and this consent must be documented.

5. Provider Credentials and Signature

The exam must be conducted and signed by a licensed professional who is authorized to practice in the patient’s state. This often includes physicians, nurse practitioners, or physician assistants.

Want to automate your GFE workflow? Qualiphy offers compliant, white-labeled Good Faith Exam services fully integrated with EMR platforms like.

Best Practices for Documenting Good Faith Exams

1. Use a Standardized Template

To reduce errors and maintain consistency, med spas should use a GFE template that prompts providers to complete each required field. This ensures nothing is missed, even during high-volume clinic days.

2. Integrate with Your EMR

Your EMR system can be configured to integrate Good Faith Exam documentation directly into each patient chart. This centralizes critical data, supports efficient audits, and ensures your workflow aligns with compliance requirements.

3. Leverage Telehealth Platforms with Branded Interfaces

Using systems like Qualiphy, patients undergo virtual Good Faith Exams under your brand name. The documentation generated is automatically saved to your EMR, and the provider remains invisible to the patient, protecting your brand equity.

4. Keep Documentation Accessible and Audit-Ready

Most state boards require records to be retained for 5–7 years. Your documentation system must support secure storage, instant retrieval, and HIPAA-compliant data management.

5. Train Staff on Protocols and Legal Implications

Your front-desk, nursing, and management teams should all be familiar with Good Faith Exam protocols. They should know what triggers the exam, how it’s scheduled, and the implications of skipping it.

What Happens If You Skip the Good Faith Exam?

The risks of bypassing a Good Faith Exam are significant. Common violations include:

Performing treatments without a documented medical evaluation
Using pre-filled forms without a real-time interaction
Conducting GFEs by unqualified personnel

Consequences can include:

Medical board investigations
Loss of malpractice insurance coverage
Civil lawsuits from patients
Negative online reviews and loss of trust

In an industry where patient outcomes and safety are paramount, these risks simply aren’t worth it.

The Role of Automation in Modern Good Faith Exams

With the rise of telehealth, many aesthetic practices are turning to automated solutions to streamline Good Faith Exams. A platform like LeadAR can trigger GFE workflows, collect documentation, and integrate with CRMs and EMRs to ensure no patient falls through the cracks.

Benefits of automation include:

Reduced manual errors
Real-time compliance alerts
Seamless integration with booking and payment platforms
Time savings for providers

Practices using Qualiphy report that patients complete payment, intake, and the Good Faith Exam within 3 minutes, all without staff involvement.

How to Know If Your Good Faith Exams Are Compliant

To audit your existing GFE process, ask yourself:

Are all exams performed by a licensed, authorized provider?
Is each exam documented with time/date, provider signature, and patient history?
Does the documentation live inside an EMR or secure system?
Can you produce this documentation instantly if audited?
Is the consent form signed and stored with the exam?

If you answer “no” to any of these, your current Good Faith Exam workflow may put your practice at risk.

State-by-State Differences in Good Faith Exam Requirements

Each state has unique laws regarding who can perform a Good Faith Exam, whether it can be virtual, and what needs to be documented. For example:

California requires the GFE to be performed in person before delegating procedures.
Texas permits telemedicine GFEs but only by certain license types.
Florida mandates that the exam be performed by the same provider who supervises the treatment.

Always check with your state medical board and consult a healthcare attorney to ensure compliance.

For more information, consult AmSpa’s State Regulatory Map to review your state’s GFE and delegation requirements.

Final Thoughts: Don’t Treat Without a Good Faith Exam

A Good Faith Exam is more than just a regulatory checkbox. It’s a cornerstone of safe, ethical, and legally sound medical aesthetic care. As virtual consultations become more prevalent and patient demand rises for fast, hands-free services, your practice must adapt without compromising standards.

With platforms like Qualiphy, automating compliant Good Faith Exam documentation has never been easier. You can grow your med spa, protect your patients, and stay compliant, all while maintaining your brand’s integrity.

External Resources:

Frequently Asked Questions (FAQs)

Can I delegate a Good Faith Exam to a medical assistant?
No. Only a licensed physician, nurse practitioner, or physician assistant may perform the exam, depending on state laws.
Does a GFE need to be done for every treatment?
A GFE is generally required for any treatment involving prescription drugs, devices, or medical-grade procedures.
How long is a Good Faith Exam valid?
It varies by state and treatment type. Some states require a new exam for each treatment; others may allow them to remain valid for a set period if the patient continues care.
Can a GFE be performed via telehealth?
Yes, in many states. However, some still require in-person evaluations. Always confirm with your local board.
What happens after the Good Faith Exam?
If the patient is approved, the treatment plan is documented, and they may proceed with scheduling. If not, they must be deferred with documentation and explanation.

About Qualiphy

Qualiphy is a white-labeled telehealth solution designed specifically for aesthetic practices and wellness clinics. It enables providers to offer nationwide, on-demand Good Faith Exams that are fully compliant, instantly documented, and seamlessly integrated with EMR platforms. Providers appear under your brand, allowing you to deliver care that protects both your license and your patient relationships.

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Disclaimer

This blog is provided for general informational purposes only and does not constitute legal or medical advice. Laws and regulations regarding Good Faith Exams vary by state and are subject to change. Always consult with a licensed healthcare attorney or regulatory expert before implementing changes to your practice.