What §169.25 actually says
The full citation is 22 Texas Administrative Code § 169.25–169.28, adopted by the Texas Medical Board (TMB) and effective January 9, 2025. The rule replaced the prior delegation-and-supervision rule (§193.17) and moved nonsurgical cosmetic procedures explicitly under the "practice of medicine" framework.
In practice, §169.25 means three things for a Texas med spa or IV clinic:
- The procedure is a medical act. A licensed physician (MD or DO) must own the clinical decision, even when delegated. This is true whether your clinic is owned by a physician, a non-clinician, or a registered nurse.
- Delegation must be documented. The medical director must have signed delegation orders tied to a named delegate (the RN, NP, PA, or other clinician actually performing the procedure), and those orders must be specific to the procedure being delegated.
- The Good Faith Exam (GFE) is mandatory. Before any covered procedure, a properly licensed clinician must perform and document a GFE. Generic patient-intake forms do not qualify as GFEs.
What's covered (and what isn't)
§169.25 covers nonsurgical cosmetic procedures that involve injection, energy delivery, or introduction of a drug or biologic. The procedures most directly affected:
- Neuromodulators — Botox, Dysport, Xeomin, Daxxify, Jeuveau
- Dermal fillers — Juvederm, Restylane, Radiesse, Sculptra, RHA, biostimulators
- IV therapy and IV hydration (also covered separately by HB 3749 — see below)
- Laser and intense-pulsed-light treatments where supervised by a physician
- Microneedling with depth or RF (microneedling without depth limits is treated separately)
- Chemical peels of medium and deep depth
- Sclerotherapy
- Hormone pellet insertion and similar minor procedures
Procedures not covered by §169.25 include strictly cosmetic services that do not introduce a drug or device — basic facials, manicures, waxing, eyebrow threading. These remain under TDLR (Texas Department of Licensing and Regulation) cosmetology rules.
Five documents inspectors ask for first
Every Texas Medical Board investigator we've talked to begins the same way: a request for five named records. A clinic that produces them in 24 hours is in dramatically better shape than one that says "let me check with my medical director."
1. The medical-director agreement
A signed contract between the clinic entity and the named physician, identifying the supervision arrangement, scope of delegated procedures, review cadence, term, and termination conditions. The agreement must be current and reflect the actual relationship — a contract from 2022 with a doctor who hasn't visited in 18 months is worse than no contract.
2. Written delegation orders for each procedure
Specific, dated, signed orders that delegate a named procedure (e.g., "Botox cosmetic injection") to a named delegate (e.g., "Sarah Lopez, RN, license number 1234567") under the supervision of the medical director. The orders must list the medications used, the protocol, contraindications, and the supervisory contact method.
3. Standing protocols
Written protocols for each delegated procedure — the clinical algorithm, dosing range, contraindications, consent process, and adverse-event response. Standing protocols must be reviewed periodically (annually at minimum) and signed off after each review. Vague "the medical director approves all procedures" language is not a standing protocol.
4. Named-credential staff IDs
Each clinical staff member must wear identification with their full credential clearly displayed (RN, NP, PA, MD). On the website team page and in any patient-facing material, the credential must be present and accurate. Aestheticians and medical assistants must be clearly distinguished from licensed clinicians.
5. Supervision logs
A log of supervised procedures — for each procedure delivered under delegation, the date, the delegate, the supervisory contact made (in-person, video, telephone), and the medical director's review where required. The log can be paper or digital, but it must exist and be retrievable.
What "supervision" means after January 9, 2025
The TMB has been explicit that "the medical director is on call" is no longer adequate supervision for nonsurgical cosmetic procedures in most contexts. The expectation is one of:
- On-site supervision — the physician is physically present
- Direct supervision via telehealth — the physician is reachable by video, with a documented response window
- General supervision with documented protocols — for low-risk procedures, the physician sets written protocols and is reachable; the supervision arrangement is documented
In every case the supervision arrangement must be documented — that is, written down, signed, and available to produce on inspection.
The Good Faith Exam — what counts and what doesn't
A Good Faith Exam (GFE) under §169.25 is a clinical evaluation performed by a properly licensed clinician (MD, DO, NP, PA — and in some narrow cases, RN under direct delegation) that includes:
- Patient identity and history relevant to the procedure
- Clinical evaluation of the area being treated
- Discussion of risks, benefits, and alternatives
- Written authorization for the specific procedure
- Documentation of the clinician who performed the exam, the date, and the patient's informed consent
The GFE can be performed in person or via documented telehealth, depending on the clinic's protocols and the patient's history. A generic patient-intake form, a check-the-boxes consent, or a "the medical director approves everyone" attestation does not satisfy the GFE requirement.
What changed for IV therapy specifically
§169.25 set the documentation framework. HB 3749 ("Jenifer's Law"), effective September 1, 2025, layered an additional restriction on top: only an MD/DO, APRN, PA, or RN — under documented physician supervision — can initiate elective IV therapy in Texas. Phlebotomists, medical assistants, and aestheticians cannot initiate IV.
This means a Texas IV clinic must have, on file, before each infusion: the supervising physician's identity, a signed delegation order for IV initiation, a standing protocol for the specific IV menu items, and a supervision log for the infusion. Read the full HB 3749 explainer.
How to know if you're compliant
The pragmatic test: can you produce, within 24 hours, all five named records above for any procedure delivered in your clinic in the last 30 days?
- If yes — keep doing what you're doing. Add a quarterly review cycle to keep the documents current.
- If no — start with the medical-director agreement and the delegation orders. Those are the spine. Standing protocols, GFEs, and supervision logs hang off them.
- If "we have it somewhere" — that's the gap §169.25 was written to close. Centralizing the evidence is the work; ProofOps Medical exists to do exactly that.
Frequently asked
Does §169.25 apply if our clinic is RN-owned and the medical director is remote?
Yes. §169.25 doesn't depend on who owns the clinic; it applies whenever a covered procedure is delivered. Remote medical directors are permitted, but the supervision arrangement, delegation orders, and standing protocols must be documented and the supervisory contact method (video, on-call, etc.) must be specified.
Are we required to use a Texas-licensed medical director?
The supervising physician must hold an active Texas Medical Board license. A physician licensed elsewhere cannot serve as the medical director for a Texas med spa unless they hold Texas licensure.
How often must standing protocols be reviewed?
The TMB has not set a single mandatory cadence in §169.25. The defensible practice is annual review with written sign-off, and immediate review when a procedure or product is added.
Does a Good Faith Exam expire?
The TMB has not specified a hard expiration. Defensible practice: a GFE is fresh for the procedure it was performed for and similar follow-up procedures within a reasonable window (commonly 12 months, sometimes shorter for higher-risk procedures). New procedure types or materially different concerns should trigger a new GFE.
What's the penalty for a §169.25 violation?
Penalties range from administrative remediation to disciplinary action against the medical director's license to civil and criminal exposure for both the medical director and the clinic owner, depending on severity. The Wortham case is the current high-water mark of criminal exposure tied to documentation deficiencies.
How ProofOps Medical helps with §169.25
ProofOps centralizes every document §169.25 asks for into one digital file: medical-director agreements, delegation orders, standing protocols, named-credential staff IDs, supervision logs, and GFE evidence. Our AI agents track expiration dates, surface missing records, and produce a monthly readiness PDF you can hand to your medical director, your insurance broker, or — if it ever comes to it — a TMB inspector.
Get a free Texas documentation audit for your clinic — we'll review what's publicly visible plus a brief intake and send you a one-page PDF showing where the §169.25 gaps are. No card. 24-hour turnaround.
This page is informational. It is not legal advice and should not be relied upon as the basis for compliance decisions. For interpretation of §169.25 specific to your clinic, consult your healthcare attorney and your medical director. Cite/source: Texas Medical Board, 22 TAC Chapter 169 (effective January 9, 2025).