When state regulators audit a Med Spa or investigate a complaint, they almost always ask for one thing first: proof that a Good Faith Exam took place.
It’s not enough to say that one was performed. You need complete, dated, and verifiable documentation showing that a licensed provider evaluated the patient and made a medical determination before treatment began.
Why Documentation Matters
A Good Faith Exam is more than a compliance requirement. It’s your evidence of safety, legality, and professional judgment. Proper documentation proves:
- The exam occurred before treatment.
- A licensed provider assessed the patient’s medical history and current health.
- The patient was determined to be an appropriate candidate for treatment.
- Informed consent for the GFE was given by the patient prior to exam initiation.
- All data was recorded, stored, and retrievable in case of audit.
Without this paper trail, it’s nearly impossible to defend your Med Spa in a regulatory or malpractice claim.
What Your Records Should Include
Every Good Faith Exam record should contain these key elements:
| Documentation Element | Description | Why It Matters |
| Patient Intake Form | Includes demographics, medications, allergies, and medical history. | Establishes the foundation for risk assessment. |
| Exam Notes | The provider’s assessment of the patient’s condition, contraindications, and findings. | Proves medical judgment and professional evaluation. |
| Provider Credentials | The full name, title, and license number of the provider performing the exam. | Confirms that a qualified professional conducted the evaluation. |
| Treatment Authorization | Documentation specifying which treatments the patient was cleared for. | Ensures procedures align with the exam scope. |
| Date and Format | Indicates when and how the exam was performed (in-person or virtual). | Confirms compliance with telehealth and timing laws. |
For additional guidance on treatment-specific requirements, see Are Good Faith Exams Required for All Med Spa Services, or Only Certain Ones.
Common Documentation Mistakes
Even well-intentioned Med Spas can make recordkeeping errors that create legal risk. The most common include:
- Missing the provider’s signature or license number.
- Recording the exam after the treatment rather than before.
- Storing files only locally (instead of in a secure, retrievable system).
- Failing to document the medical rationale for clearance.
- Omitting the patient’s acknowledgment of informed consent.
If any of these are missing, your Good Faith Exam may be considered invalid by a state board or insurer.
How Spakinect Simplifies Documentation and Compliance
Spakinect’s platform was designed to eliminate documentation errors and strengthen your compliance record.
- Patients connect with a provider in an average of 31 seconds
- Exams are performed by licensed and professional W-2 providers who receive an additional 40+ hours of compliance and medical aesthetics education
- All documentation is automatically stored and retrievable through your client portal
- Systems are vetted by Medical Boards and legal experts for audit readiness
- Spakinect currently operates in 40 states and counting, providing consistent compliance coverage for both single- and multi-location Med Spas
To confirm your coverage area, visit States We Service.
FAQs: Documenting Good Faith Exams
What proof do I need that a Good Faith Exam occurred?
A completed exam record signed and dated by a licensed provider showing patient evaluation and clearance before treatment.
Can electronic documentation replace paper records?
Yes, as long as the system meets HIPAA and state telehealth storage standards.
Should patient consent be part of the Good Faith Exam record?
Absolutely. Consent forms demonstrate that the patient understood the risks and benefits discussed during the exam.
Who can sign off on a Good Faith Exam?
Only a licensed MD, NP, or PA. Read Who Can Perform a Good Faith Exam.
Does Spakinect store these records automatically?
Yes. Every exam is documented, time-stamped, and securely stored in the client portal for full traceability.
Final Takeaway
A properly documented Good Faith Exam is your strongest protection against compliance violations and malpractice claims. It proves that your Med Spa followed the law, prioritized safety, and exercised medical judgment before treatment.
Spakinect ensures that documentation is never an afterthought. With professional, licensed providers, Medical Board–vetted systems, and integrated recordkeeping, you’ll always have complete, audit-ready proof that your practice delivers care the right way… every time.
