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Chaperone Policy

Policy

MSU Health Care is committed to providing a safe environment for patients and staff. All patients are entitled to have their medical interactions conducted with appropriate privacy and confidentiality protections.

Informed consent will be obtained for all sensitive examinations, treatments, procedures, or consultations.

Patients are entitled to have a Chaperone and a Support Person present for any examination, treatment, procedure, or consultation. Chaperones must be offered for sensitive examinations, treatments, procedures, or consultations, as defined below, but may be declined by the patient or the patient’s parent, guardian, or authorized legal representative. Providers who are contracted to work in non-MSU Health Care organizations must follow the policies of that organization.

Purpose

All medical interactions have the potential to be uncomfortable or difficult for patients. Medical examinations, treatments, or procedures, including sensitive examinations, treatments, procedures, or consultations, may predispose patients to feelings of vulnerability and emotional discomfort. Patient response to those feelings will vary based on individual beliefs, religion, culture, and experience. Emphasis on privacy and the presence of a Chaperone provide benefits to both patients and Providers.

Definitions

  1. Chaperone: An authorized member of the health care team who has been trained in the prevention of sex discrimination (including but not limited to sexual harassment, sexual abuse, and/or sexual assault) and is outside of the direct chain of command of the Provider for whom they are chaperoning.
  2. Informed consent: A clear explanation of an exam, treatment, or procedure; reasonable alternatives; indications and contraindications, as applicable; and patient-verbalized understanding of the discussion.
  3. Provider: Any person employed by MSU Health Care who provides examination, care, treatment, procedures, or consultation.
  4. Sensitive examinations, treatments, procedures or consultations: Those that occur with the patient disrobed, partially disrobed, or in street clothing that involve or expose the breasts (for females), genitalia, or rectum. Examples include: breast exams, procedures of the pelvic floor or urogenital diaphragm, and vaginal or rectal exams.
  5. Support Person: A person identified by the patient who offers emotional or communication support or encouragement.
  6. Universal Precautions: An approach to infection control. All human blood and certain body fluids are treated as if known to be infectious for HIV, HBV, and other bloodborne pathogens. Body fluids include: semen; vaginal secretions; cerebrospinal, synovial, pleural, pericardial, and amniotic fluid.

Effective Date: 4/15/2017

Last Review/Revise Date: Aug 2020

Responsible Department: Clinical Operations

Policy No. CP-15h

Process

  1. Always provide an appropriate gown, allow privacy for undressing and dressing, and employ appropriate disrobing and draping practices to maximize the patient’s physical privacy.
  2. Do not allow medical students or other parties to observe sensitive examinations, treatment, procedures, or consultations without the patient’s informed consent.
  3. Universal Precautions shall be followed for sensitive examinations, treatments, procedures, or consultations, or direct digital contact with oral mucosal areas.
  4. A clear explanation of the nature of any examination or treatment must be given to the patient, and, as applicable, the Chaperone, Support Person, parent, and/or the patient’s legally authorized representative.
    1. Written explanations stating how and why sensitive examinations, treatments, procedures, or consultations are to be performed will be provided to patients.
  5. Informed consent will be obtained prior to beginning any sensitive examinations, treatments, procedures, or consultations.
    1. If the patient is under the age of 18, lacks decision-making capacity, or declines to participate in decision-making, the Provider or staff will obtain informed consent from the patient’s legally authorized representative.
    2. No sensitive examination, treatment, procedure, or consultation can be performed until informed consent is obtained or a Provider makes a determination that the patient needs immediate medical care and further delay would increase the risk to the patient’s life or health.
    3. Informed consent to a sensitive examination, treatment, procedure, or consultation will be documented in the medical record.
    4. Patients will have an opportunity to consult with the Provider to resolve any questions or concerns prior to treatment.
    5. Patients will be notified of the right to terminate an examination, treatment, procedure, or consultation at any time.
  6. For any physical examinations of a patient under the age of 18, the parent, guardian, legally authorized representative, or person in loco parentis shall always be present. If they are unavailable or the parent’s presence will interfere with the physical examination, such as in a possible case of abuse or parental mental health issues, their presence is not required.
  7. A patient’s request to have a Support Person present will always be honored.
  8. Education on the role of a Chaperone will be provided to patients.
  9. Patients will be notified of the availability of a Chaperone in a clinic’s “welcome letter” and posting in examination rooms.
  10. A Chaperone will be made available to any patient upon request, even if the patient has a Support Person present. Patients, parents, legally authorized representatives, Support Persons, and Providers may request a Chaperone at any time.
  11. If a Chaperone is requested and none is available at that time, the patient must be given the opportunity to reschedule their appointment within a reasonable timeframe.
  12. The patient’s wishes and comfort should determine the gender of the Chaperone. To the extent practicable, the patient’s request for a same gender Chaperone will be accommodated.
  13. Chaperones are required for all sensitive examinations, treatments, procedures, or consultations unless specifically declined in writing by a patient, parent, guardian, or legally authorized representative.
    1. The name of the Chaperone must be documented in the medical record.
    2. If a patient, parent, guardian, or authorized legal representative declines a Chaperone for a sensitive examination, treatment, procedure, or consultation, the declining patient, parent, guardian, or authorized legal representative must sign a document indicating that they were offered a Chaperone, but declined, before the examination, treatment, or procedure may proceed.
    3. In the event a patient requires successive visits for the same sensitive examination, treatment, procedure, or consultation, a single waiver document may be used, given that the duration of the waiver does not exceed twelve months.
  14. In the event a Provider or clinic medical director believes there exists a compelling reason to waive components of this policy for specific types of patients in non-emergency situations, approval for that waiver must be requested and granted by the MSU Health Care Board, before such a waiver may take effect.
  15. Providers who violate this Policy will be subject to disciplinary action, up to and including termination of employment or contract with MSU.

Chaperone Policy Frequently Asked Questions

 

  • What is a chaperone?
    A chaperone is an observer who may assist our patients and providers during sensitive examinations, treatments, or procedures, or upon request. Chaperones protect both patients and providers by helping create a neutral, safe, respectful environment.
  • Who can serve as a chaperone?

    The chaperone may be a trained health professional or staff member. We will make every effort to ensure the chaperone is the gender the patient is most comfortable with. Family members and friends of adult patients should not serve as chaperones but may be present during chaperoned procedures if the patient requests.

  • What does the chaperone do?

    A chaperone provided by MSU Health Care has many responsibilities. These include providing emotional comfort, providing gowns/sheet to ensure privacy, assist with interpreting instructions, and ensure continuing consent to the exam/treatment/procedure. They do not need to be present through-out a patient visit with their provider such as when discussion of health history is being gathered. The chaperone will stand in an unobtrusive location during the procedure and aid the provider and support to the patient if needed.

    Any chaperone who witnesses inappropriate or unacceptable behavior on the part of a healthcare provider is required to report it immediately.

  • When will I have a chaperone?

    Chaperones are required for “sensitive” exams and procedures and will be present unless you waive their presence. MSU Health Care patients also have the right to have a chaperone present for any treatment, exam, procedure, or consultation. If you would like to have a chaperone, let your provider know. If you notify the clinic in advance, they can plan to have a chaperone available. If you ask for a chaperone at any time during your visit, your provider will not proceed until a chaperone is available.

  • Can I decline to have a chaperone present during an exam or procedure?

    Chaperones are intended to create a safe environment for both patients and providers.

    Adult patients who are able make their own medical decisions have the right to decline the presence of a chaperone by signing a waiver (this will be noted in the patient record).

    Minor patients: Parents may decline the presence of a chaperone for a patient under the age of 18 by signing a waiver. However, providers may decide not to perform an exam or procedure without a chaperone present.

    Six and under patients: Parents, guardians, or legally authorized representatives of children age six (6) and younger will be permitted to decline verbally, and the declination will be documented by staff in the electronic health record rather than in a signed form.

  • What is a “sensitive” exam or procedure?

    A sensitive examination or procedure includes the physical examination of or a procedure involving the genitalia or rectum (regardless of gender) or female breast. No sensitive examinations will be performed via telehealth.

    View the Patient Guide to Adult Sensitive Exams

    View the Patient & Family Guide to Pediatric Sensitive Exams