A board reads your chart to answer four questions: who examined this patient, what they found, what they ordered, and who carried it out. The rules that spell it out agree on the core. The record needs a history, exam findings, an assessment, a plan naming the drug, dose and route, informed consent, emergency and follow-up instructions, and the names of the person who ordered and the person who treated.
Washington wrote the checklist into a rule
Most states leave the contents of the exam to the standard of care. Washington wrote them down. Before authorizing a nonsurgical medical cosmetic procedure, a physician must “(a) Take a history; (b) Perform an appropriate physical examination; (c) Make an appropriate diagnosis; (d) Recommend appropriate treatment; (e) Obtain the patient’s informed consent; (f) Provide instructions for emergency and follow-up care; and (g) Prepare an appropriate medical record” (WAC 246-919-606(5)). The same rule makes the physician “responsible for ensuring that each treatment is documented in the patient’s medical record” (subsection (7)).
If you operate in a state that has not written its own list, this one is the safest template to build a form around. Seven items, in the order a reviewer looks for them.
Texas ties the exam to its records chapter
The Texas delegation rule requires that, before the delegated act, the physician, PA or APRN “complete and maintain an adequate medical record in accordance with Chapter 163 of this title” (22 TAC § 169.26(c)(2), effective January 9, 2025). Chapter 163 is specific. The record “must be a complete, contemporaneous, and legible documented account of each patient encounter,” and it must include “a reason for the encounter, relevant history, physical examination findings (ensuring any pre-populated fields contain current and accurate patient information), and any diagnostic test results” (§ 163.1).
That parenthesis is aimed at template charting. A good faith exam note where every patient has the same normal findings, carried forward from a default, is the record this rule describes. Late entries must show the time, date and author. Amendments must be identified, with the original text still legible.
The written order is a second document. It must name the delegating physician, state the “selection criteria for screening patients,” describe appropriate care, and set out procedures for complications and emergencies (§ 169.27(b)). The order tells staff whom they may treat. The exam note shows that this patient met it.
Florida wants to know who ordered and who supervised
Florida’s records rule requires “patient histories; examination results; test results; records of drugs prescribed, dispensed, or administered” and enough to “justify the treatment” (Fla. Admin. Code r. 64B8-9.003(3)). The disciplinary statute adds the part clinics miss: the record must identify, “by name and professional title,” the physician or the extender and supervising physician “responsible for rendering, ordering, supervising, or billing for each diagnostic or treatment procedure” (Fla. Stat. § 458.331(1)(m)).
For weight management and IV programs, read paragraph (4) of the same rule. When a compounded medication is administered in the office, the chart must carry the name and concentration, the lot number, the expiration date, the compounding pharmacy or manufacturer, the site of administration, the amount and the date. If your IV therapy charts say “Myers cocktail” and nothing else, they do not meet it.
The chart elements, side by side
| Element | Washington | Texas | Florida | Rhode Island | Ohio |
|---|---|---|---|---|---|
| History | WAC 246-919-606(5)(a) | § 163.1 | 64B8-9.003(3) | RIDOH guidance | 4731-37-01(C)(7) |
| Examination findings | (5)(b) | § 163.1 | 64B8-9.003(3) | RIDOH guidance | 4731-37-01(C)(7) |
| Diagnosis or assessment | (5)(c) | § 163.1 | supports the diagnosis | RIDOH guidance | 4731-37-01(C)(7) |
| Plan, with drugs | (5)(d) | § 163.1 | drugs prescribed, dispensed or administered | drugs including IV fluids | treatment plan |
| Informed consent | (5)(e) | § 23-105-2(c)(3) | joint statement; 4731-37-01 | ||
| Emergency and follow-up | (5)(f) | § 169.27(b) in the order | |||
| Who ordered, who performed | (7) | § 169.26(c)(3) disclosure | § 458.331(1)(m) | § 23-105-2(e) |
Rhode Island’s Department of Health lists seven items, and the last three are the ones boards elsewhere imply: “the nature and purpose of recommended interventions,” “the burden, risks, and expected benefits of all options, including foregoing treatment,” and the “patient’s decision.” Ohio’s three boards, in their May 15, 2025 joint statement on retail IV clinics, require the prescriber to “create a comprehensive medical record that complies with the standard of care” and to document informed consent “prior to the delivery of care.” A blank cell above means we did not find that element written into that state’s rule. It does not mean the standard of care there ignores it.
A valid order is patient-specific
The clearest description of what an order must contain comes from a nursing board. Massachusetts requires the nurse to verify that the order from an authorized prescriber includes the patient’s name, a valid order date, the medication or substance, dosage, route, anatomical site, specific administration directions and the prescriber’s signature (Advisory Ruling 13-01, revised January 10, 2024). New York’s Office of the Professions says a registered nurse executes regimens “ordered for a specific patient by a physician or other qualified health care practitioner who has examined the patient.”
Both describe the same document. A menu with a checkbox is not that document.
Telehealth exams are charted to the in-person standard
Florida says a telehealth provider documents “according to the same standard as used for in-person services” (Fla. Stat. § 456.47(3)). Texas holds telemedicine to the standard of care “that would apply to the provision of the same health care service or procedure in an in-person setting” (Tex. Occ. Code § 111.007(a)). Ohio requires the provider to “promptly document” consent to telehealth, pertinent history, evaluation, diagnosis, treatment plan, underlying conditions, contraindications and referrals (OAC 4731-37-01(C)(7)).
A two-line video note fails all three. The North Carolina Medical Board’s records statement, amended in January 2026, warns that documentation “must accurately and contemporaneously reflect the actual care provided,” and cautions against cloned content. If a scribe tool writes the note, the prescriber still owns every word. For where video is allowed at all, see the telehealth rules.
How long you keep it
- Florida: at least five years from the last patient contact (r. 64B8-10.002). The rule itself warns that this may be shorter than you need to protect yourself.
- New York: at least six years (8 NYCRR § 29.2).
- California: at least seven years after the last date of service, written into Bus. & Prof. Code § 2266 effective January 1, 2024.
- Texas: at least seven years from the date of last treatment (22 TAC § 163.2).
- Rhode Island: at least seven years, per the Department of Health guidance.
- Georgia: no less than ten years from the last office visit (r. 360-3-.02(16)(a)).
- Tennessee: not less than ten years from the last professional contact (0880-02-.15(4)(f)).
A multi-state operator should set one retention policy at the longest period that applies to it.
What this means for you
Pull ten charts at random and read them as a board would. For each treatment, find the assessment that supports it, the order that names the drug, dose, route and site, the consent, and the names of the prescriber and the person who treated. Where findings are identical across patients, fix the template before you fix anything else. Add lot number, expiration and pharmacy to every compounded or IV administration record. Then write down who owns the record and for how long, because the record is what you are buying when you pay for an exam. Our own charting expectations are in clinical standards, and the elements of the exam itself are in good faith exam requirements.
Related reading
Frequently asked questions
What should a good faith exam include?
A history, examination findings, an assessment or diagnosis, a treatment plan naming the drug, dose and route, informed consent, and instructions for emergencies and follow-up. Washington lists these in WAC 246-919-606(5). Texas, Florida, Rhode Island and Ohio require the same core through their medical records rules, and Florida adds the name and title of whoever ordered and supervised.
Does the medical director have to sign every chart?
We found no rule, in the states we opened, that sets a deadline in hours or days for a prescriber’s signature. Texas requires records to be contemporaneous, Ohio says promptly, and Florida requires entries to be dated. Florida also says a supervising physician may not be required to review and cosign a physician assistant’s charts. The order itself still needs a prescriber.
Can I use a template for good faith exams?
Yes, with care. Texas requires that any pre-populated fields contain current and accurate patient information, and the North Carolina Medical Board cautions against cloned or carried-forward content. A template that prompts the examiner is fine. A template that fills in normal findings nobody checked produces a record that reads as no exam.
How long do I have to keep good faith exam records?
It depends on the state. Florida requires at least five years from the last contact, New York six, California, Texas and Rhode Island seven, and Georgia and Tennessee ten. If you operate in more than one state, set a single policy at the longest period that applies to you.
This is general information, not legal advice. Rules vary by state and change. Confirm your own facts with counsel.