Policy

MSU HealthTeam 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-HealthTeam 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 the HealthTeam 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.

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 HealthTeam 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.

Effective Date: 4/15/2017

Last Review/Revise Date: Aug 2020

Responsible Department: Clinical Operations

Policy No. CP-15h

Appendix A

The Memo below was approved by the MSU Health Care Governing Board of Directors on May 21, 2021. The exception will allow parents, guardians, or authorized legal representatives to verbally decline a chaperone for children six (6) years old and younger. The declination will be documented in the electronic health record.

Where can I learn more about MSU Health Care's Chaperone Policy?

What is a Chaperone?

View the Patient Guide to Adult Sensitive Exams

View the Patient/Family Guide to Pediatric Sensitive Exams