What Is a Good Faith Exam, and What Does the Record Have to Show?
Published September 24, 2026 · 6 minute read · General information, not legal advice. Your licensing regulators decide what applies to you.
Owners search this phrase for one of two reasons. A consultant told them every patient needs one before treatment and they want to know what that means in practice. Or an insurer, a prescriber, or a prospective employer asked to see how theirs are documented, and they were not sure what the document was supposed to look like.
The phrase itself is informal. There is no single national definition of a good faith exam. It is shorthand used in the aesthetic and infusion industry for the evaluation a qualified clinician performs before a patient is treated, and for the record that evaluation leaves behind. Treat the phrase as a label for a document and the question becomes answerable.
This guide describes what that record generally contains and where it sits in the rest of the file. It does not say who may perform the evaluation, how recent it has to be, whether a remote evaluation counts, or how long the record has to be kept. Those answers come from the licensing regulators for the professions involved, and they are not the same everywhere. The guide on how to verify what your state actually requires covers how to get that answer in writing from the body that issues it.
The evaluation is an event. The record is what survives it
The evaluation happens once, in a room or over a video connection, and then it is gone. Everything anyone asks about it afterwards has to be answered from the record: whether it happened, who did it, what they found, and what they authorized on the strength of it.
That is the practical reason to think of the good faith exam as a document rather than as a step in a workflow. A practice that treats it as a step tends to record the fact that it happened. A practice that treats it as a document records enough for a reader who was not there to follow the reasoning.
What the record usually contains
Most versions of this document carry the same fields, whatever a practice calls it:
- Patient identification, date, and time. Time matters because the treatment record has to be traceable back to an evaluation that preceded it.
- Who performed it. Name, credentials, and license number of the clinician, written out rather than initialled.
- How it was performed. In person, or by live interactive technology. If remote, which platform, and whether the patient was seen and heard in real time.
- History collected. Relevant medical history, current medications, allergies, prior treatments in this category, and anything the patient reported that bears on suitability.
- Findings. What the clinician observed, in their own words.
- Assessment and authorization. What the clinician concluded, and which service categories they authorized as a result.
- What was not authorized. Anything declined, deferred, or made conditional, with the reason. This field is the one most often left off, and the one that does the most work when a decision is questioned later.
- Consent reference. A pointer to the consent document for the service, rather than consent language folded into the evaluation record itself.
- Signature and date. Signed by the clinician who performed the evaluation, not by whoever transcribed it.
Two of these carry most of the weight. The authorization field is what a treatment record points back to. The field for what was not authorized is what shows a reader that a judgment was exercised rather than a box ticked.
Where practices get caught short
Four patterns come up repeatedly when an owner is asked to produce these records.
The evaluation exists only as an intake questionnaire the patient filled in. A form completed by the patient records what the patient said. It does not record what a clinician concluded from it, and on its own it leaves the assessment and authorization fields empty.
The evaluation was documented once and never revisited, while the patient's service menu grew. Nothing in the file connects the later treatments to an evaluation that considered them.
The treatment record and the evaluation record live in different systems with no shared identifier, so tracing one to the other takes a person and an afternoon.
The record shows a name but not credentials or a license number, which means an outside reader cannot establish who performed it without asking.
What one published standard says about evaluation and the record
The Federation of State Medical Boards, the national association of the boards that license physicians, adopted a report in April 2022 on the use of telemedicine technologies in medical practice. It states that "a documented medical evaluation and collection of relevant clinical history commensurate with the presentation of the patient to establish diagnoses and identify underlying conditions and/or contra-indications to the treatment recommended/provided must be obtained prior to providing treatment, including issuing prescriptions." The same document says that diagnosis or treatment "based solely on static online questionnaires" is not acceptable, and that the medical record should include copies of patient-related electronic communications, evaluations, and consultations. The full text is published by the FSMB as The Appropriate Use of Telemedicine Technologies in the Practice of Medicine.
That document is a model policy written for licensing boards. It is not law, and it is not a description of what applies in any particular practice. It is cited here because it is a clear published statement, from a body with standing, of the principle that the evaluation and the record of it come before treatment. What any individual practice has to do is set by its own regulators. The regulator directory lists them.
Where the record sits in the file
The evaluation record is one of four documents that reference each other for a single patient encounter: the evaluation record, the consent for the specific service, the treatment record, and, where a practice operates under physician oversight, the supervision or delegation record that establishes who authorized whom. Each should carry an identifier that lets a reader move to the next without guessing. The guide on whether you need a medical director covers the oversight document underneath all of this.
Where our documents fit
The Intake and Screening Module has blank screening and evaluation records with these fields, and the Medical Director Oversight Module has the oversight records the evaluation points back to. They are blank where the clinical and jurisdictional decisions belong. They do not tell you who may perform an evaluation or how recent it has to be.
This week
- Pull the last five treatment records in the practice and trace each one back to the evaluation record that authorized that service, using only what is written on the documents.
- Note where the trail breaks: a missing identifier, a missing license number, an authorization that does not name the service performed, an evaluation that predates a service category it never mentions.
- Add a field for what was not authorized to whichever form you use, and start filling it at the next evaluation.
- Intake and Screening Module, $29
- Medical Director Oversight Module, $34
- Complete Charting Bundle, 12 records, $27
Questions this guide answers
Is a good faith exam the same as a consultation?
Not necessarily. A consultation is often a conversation about options and pricing, and it may be conducted by someone who is not a clinician. The evaluation described here is a clinical assessment that produces a record and an authorization. Some practices combine them in one appointment, but the two documents should stay distinguishable.
Can the evaluation be done remotely?
That depends on the professions involved and the regulators that license them, and it is not the same everywhere. What the record should show, if the evaluation was remote, is how it was conducted and whether the patient was seen and heard in real time.
Does a patient need a new evaluation for every visit?
The interval is set by the practice's regulators and by clinical judgment, not by a general rule. What causes problems in the file is a treatment in a service category the existing evaluation never addressed. Recording what was authorized, and what was not, makes that gap visible early.