Medical Chaperone

Policy number03-01
Responsible officeGeneral Counsel
Enforcement officialThe Director of each WMU Healthcare Operation is responsible for communicating, updating and enforcing this Policy.
ClassificationBoard of Trustees Policy
Category07. Clinical Training and Operations

Statement of policy

It is WMU’s Policy that, for the protection of the patient and the WMU Healthcare Provider, any patient or Provider may request that a second healthcare professional serve as a chaperone during any medical examination.  Unless waived by the patient, chaperones must attend all Sensitive Examinations.

Summary of contents/major changes

This Policy sets forth WMU’s expectations regarding having chaperones present during clinical examinations. Chaperones are optional for non-Sensitive Examinations, but are required for Sensitive Examinations. The Provider must document any refusal by the patient to have a chaperone. Refusal to have a chaperone present may result in transfer of care in non-emergency situations.

1. Purpose of policy

This Policy identifies the situations in which WMU expects that patients and Providers be given the opportunity to have a chaperone present in the examination room. Having a chaperone present in examinations protects both the patient and the Provider. Due to the issues surrounding Sensitive Examinations, unless the patient waives the requirement, chaperones are required for Sensitive Examinations.

WMU recognizes and is committed to inclusion of all genders and gender expressions that make up our community. However, there may be some situations in which a medical provider must use anatomical definitions when discussing body parts.

2. Stakeholders most impacted by this policy

Any WMU healthcare provider or patient at WMU healthcare operations.

3. Key Definitions

3.1. Chaperone
A trained member of the WMU Healthcare Operation staff who will be in the examination room while the Provider is physically examining the patient.  Chaperones may not be family members or guests of the patient.
3.2. Sensitive Examination
Generally, an examination of the patient, whether they are disrobed, partially robed or in street clothing, involving the breasts, genitalia, or rectum. The term “examination” also includes treatment and procedures. Examples include: breast exams, procedures of the pelvic floor or urogenital diaphragm, vaginal or rectal exams. The patient’s and the Provider’s perceptions will be considered when determining whether an examination is sensitive. Religious or cultural requirements and preferences should also be considered.
3.3. WMU Healthcare Provider (Provider) or Examiner
A licensed healthcare provider who works at or is privileged at a WMU Healthcare Operation.
3.4. WMU Healthcare Operation
Sindecuse Health Center, Unified Clinics, Department of Athletics (including while travelling for athletic or other official events).

4. Policy

4.1. Use of Chaperones

4.1.1. The University expects that all Providers will discuss with patients, including minors, the option of having a second health professional serve as a chaperone during examinations.

4.1.2. A chaperone should be present for a medical exam whenever a patient or a Provider requests this service.

4.1.3 A chaperone must be present at all Sensitive Examinations unless refused by patient.

4.2. Examiner Duties

4.2.1. Examiner should honor a patient’s request to have a chaperone present during a non-Sensitive Examination.

4.2.2. A chaperone must accompany an Examiner for any Sensitive Examination unless refused by the Patient.

4.2.3. Examiner should clearly inform chaperones that they must uphold professional standards of privacy and confidentiality.

4.2.4. If medically feasible, examiners should hold inquiries or taking sensitive patient histories until the chaperone has left the examination room.

4.2.5. Examiner should allow an opportunity for the Patient to have a private discussion with the Examiner without the chaperone present.

4.3. Chaperone Duties

4.3.1. Chaperones shall uphold professional standards of privacy and confidentiality, be sensitive and respect the patient’s dignity and confidentiality, reassure the patient if they show signs of distress or discomfort, be familiar with the procedures involved in a routine Sensitive Examination, stay for the entire physical examination, and be able to see what the Provider is doing.

4.3.2. Chaperones must report any good faith concerns regarding the Provider’s behavior or actions.

4.3.3. So long as reports are made in good faith, chaperones will not be subject to disciplinary action or other retaliation based on those reports.

4.4. Patient Rights

4.4.1. WMU Healthcare Operations should accommodate patient preference as to chaperone gender whenever appropriate and feasible.

4.4.2. If a chaperone of the requested gender is not available, the Patient shall be given the opportunity to reschedule the appointment within a reasonable amount of time from the originally scheduled date.

4.4.3. If a patient refuses to have a chaperone for an examination where one is required or one where the Provider has requested a chaperone, WMU may transfer care to another provider or clinic.

4.4.3.1. The Provider must document the Provider’s discussion with the patient regarding WMU’s chaperone requirement and the patient’s refusal.

4.4.3.2. In a non-emergency situation, the Provider may either perform the examination without a chaperone or refer the patient to another qualified Provider. The Provider must document the referral and the reason for it.

4.5. Communication

4.5.1. The University Community will be notified of this Policy via its posting on the University’s Policy page and standard departmental communication processes.

4.5.2. Patients will be notified of the availability of chaperones via any “welcome” materials and visible posting throughout WMU Healthcare Operations.

5. Accountability

Providers or WMU Healthcare operations that do not comply with this Policy could lose funding, privileges on campus, or be reported to state licensing boards.

Additional consequences for non-compliance include possible individual disciplinary procedures for failure to follow applicable University policies and requirements.

6. Related procedures and guidelines

Sindecuse Health Center Patient Rights and Responsibilities available at http://wmich.edu/healthcenter/about/operations/rights.

7. Additional policy information

N/A

8. FAQs

8.1. My patient has another adult accompanying her. Do I still need to offer a chaperone? Yes.
8.2. When does the chaperone enter/exit the examination room? The chaperone should enter just prior to the examination and leave immediately following.
8.3. Does the chaperone have to be in the room during the discussion/interview portion of the examination? No.
8.4 If my patient refuses to have a chaperone, but I prefer to have one, must I continue the examination without a chaperone? No. If, in your expert opinion, you require a Chaperone for the examination you are being asked to provide and the patient refuses, you do not have to provide the examination. You must document the patient’s refusal and then work with the patient or administrative staff to find a different provider for the patient.

Related policies, procedures and guidelines

History

Effective date of current versionNovember 7, 2018
Date first adoptedNovember 7, 2018
Proposed date of next reviewNovember 7, 2021

Authorization

Certified by

Kathy Beauregard, Director, Department of Athletics; Lisa Marshall, Director, Sindecuse Health Center; Carol Sundberg Director, Unified Clinics; Direction of the Board of Trustees, Kahler B. Schuemann, Secretary of the WMU Board of Trustees

At the direction of

Board of Trustees