Chaperone Policy

If you would like a chaperone to be present during any part of your consultation including intimate examinations, then please inform your doctor. In the event of the practice being unable to provide a chaperone at that time, you will be given the option of re-booking your examination for a subsequent date.

Greenway Community Practice is committed to providing a safe, comfortable environment where patients and staff can be confident that best practice is being followed at all times and the safety of everyone is of paramount importance.

This Chaperone Policy adheres to local and national guidance and policy i.e. ‘NCGST Guidance on the role and effective use of chaperones in Primary and Community Care settings’. GMC Guidance on Intimate examinations and Chaperones March 2013 Improving Chaperoning practice in the NHS : NHSE Dec 2025

The Chaperone Policy can be read at the Practice upon request. A Poster is also displayed in the Practice Waiting Area.

A chaperone can be defined as: another individual present during a patients examination or at the request of the patient or staff; and could be a relative or another member of the practice team, such as a nurse, HCA or administration staff member. Their role can be considered in any of the following areas:

• Emotional comfort and reassurance to patients
• Showing sensitivity and respect of the patient’s dignity and confidentiality
• Assist in examination (e.g. during IUCD insertion) if familiar with the procedure involved.
• Assist in undressing
• Acting as interpreter
• Prepared to raise concerns if concern about the clinicians behaviour or actions
• Protection to the healthcare professional against allegations / attack

All patients are entitled to have a chaperone present for any consultation, examination or procedure where they consider one is required. The chaperone may be a family member or friend, but on occasions a formal chaperone may be preferred.

The practice advises that all patients are offered the option of a chaperone during any intimate examination and the fact and outcome recorded in the patients’ medical notes, there is an EMIS Web/ARDENS clinical template for clinicians to use for recording purposes, communicating the purpose and role of a chaperone in culturally appropriate and respectful language.

Staff must demonstrate cultural sensitivity and respect each patient's individual values regarding privacy, dignity and intimacy. When offering or providing a chaperone, staff should consider the patient's preferences as to choice of chaperone, including considerations relating to sex, religious beliefs or other personal circumstances.

Chaperones should be offered for intimate examinations in which patients are likely to feel stressed and/or embarrassed. This includes examination of breasts, genitalia or rectum, but could also include any examination where it is necessary to touch or even be close to the patient.

Patients are advised to ask for a chaperone if required, at the time of booking an appointment, if possible, so that arrangements can be made and the appointment is not delayed in any way. The Healthcare Professional may also require a chaperone to be present for certain consultations. If a chaperone is requested, a relative or member of the practice team need to be made available. This occasionally may necessitate rescheduling the procedure.

All staff are required to read the Greenway Chaperone Policy as part of their induction and to refresh their knowledge at appropriate time intervals.

All clinicians and those who may be called upon to act as a chaperone should undertake the appropriate on line training at e-learning for health, in order to understand their role and responsibilities and to ensure competency to perform that role.

Presence of Family members or Carers

The presence of a family member, parent or carer does not replace the need for a practice staff member chaperone. However the patient may wish to decline the offer of a chaperone if the feel their family member or carer is able to provide the support they need.

Young People – Age 13-15 and children

For Information Governance purposes and for GDPR compliance, children aged between 13 and 15 need a declaration of competence to be able to manage their own health care. A GP will make the decision if a child is competent, known as Gillick or Fraser competency.

A child of this age can be offered a chaperone in the appointment and if they attend with someone eg a parent/carer, they should be asked if they are happy to have that person with them

Any intimate examination on children and young people under 18 years should be carried out in the presence of a formal chaperone. A parent, carer  or someone known and trusted by the child may also be present during the examination or procedure to provide reassurance. Parents or guardians must receive an appropriate explanation of the procedure to provide informed consent when the young person is unable to do so themselves.

Checklist for consultations involving intimate examinations

• Chaperones are most often required or requested where a male examiner is carrying out an intimate examination or procedure on a female patient, but the designation of the chaperone will depend on the role expected of them, whether participating in the procedure or providing a supportive role.
• Establish there is a genuine need for an intimate examination and discuss this with the patient and whether a formal chaperone (such as a nurse) is needed.
• Explain to the patient why an examination is necessary and what it involves in a way the patient can understand as well as to give the patient an opportunity to ask questions. The chaperone would normally be the same sex as the patient and the patient will have the opportunity to decline a particular person as a chaperone, if that person is considered not acceptable for any reason.
• Offer a chaperone or invite the patient to have a family member / friend present.
• If the patient does not want a chaperone, record that the offer was made and declined in the patient’s notes. If the practitioner is unhappy about the refusal, they should not proceed without seeking advice from a senior colleague.
• Obtain the patient’s consent before the examination and be prepared to discontinue the examination at any stage at the patient’s request.
• In situations where the patient is unable to give consent e.g. those with impaired mental function or under the influence of drugs, a chaperone must be present during an intimate examination.
• Record that permission has been obtained in the patient’s notes.
• Once the chaperone has entered the room, they should be introduced by name and the patient allowed privacy to undress / dress. Use drapes / curtains where possible to maintain dignity. There should be no undue delay prior to examination once the patient has removed any clothing.
• Explain what is being done at each stage of the examination, the outcome when it is complete and what is proposed to be done next. Keep discussion relevant and avoid personal comment.
• If a chaperone has been present, record that fact and the identity of the chaperone in the patient’s notes.
• During the examination, the chaperone may be needed to offer reassurance, remain alert to any indication of distress but should be courteous at all times.
• Record any other relevant issues or concerns in the patient’s notes, immediately following the consultation.
• Chaperones should only attend the part of the consultation that is necessary – other verbal communication should be carried out when the chaperone has left.
• Any request that the examination be discontinued should be respected.
• Healthcare professionals should note that they are at an increased risk of their actions being misconstrued or misrepresented, if they conduct intimate examinations where no other person is present.

Data Recording

Details of the examination including the presence or absence of a chaperone must be documented in the patient’s medical records.  The identity of the chaperone, where they stood and any role they undertook must also be recorded.  The clinician should also record that permission was obtained from the patient.

All data relating to chaperones should be added when using the relevant clinical procedure templates as this is now incorporated into the Snomed templates.

Terms

• Clinician explanation of need for chaperone
• Patient requests chaperone
• Chaperone offered
• Provision of Chaperone refused
• Chaperone present
• Chaperone not available
• Verbal consent for examination

Guidance for chaperones

• Your role is to be a witness during any intimate examination to protect both patient and doctor/nurse.
• You should be introduced when you enter the room so the patient knows who you are and consents to you being there.
• You should stand at the head-end of the bed and only really get involved in conversation if the patient talks to you, thus avoiding any embarrassment for both parties.
• The patient should be left alone when getting dressed but the chaperone should wait until he/she has come out before leaving the room.
• Neither doctor nor chaperone should help the patient dress or undress, unless clarified with the patient that assistance is required.

Training for chaperones

Members of staff who maybe required  to undertake a formal chaperone role (this includes health care professionals and non-clinical staff) undergo training in the above guidelines so that they understand the following:

• What is meant by the term chaperone
• What is an “intimate examination”
• Why chaperones need to be present
• The rights of the patient
• Their role and responsibility
• Policy and mechanism for raising concerns

Information Governance advice on chaperones during video consultations

If a patient requests that a chaperone is present for a video call there are a couple of circumstances where the online process may vary: 

If the GP is based within a GP practice they should offer to have another member of staff present from within the practice – if possible whilst maintaining social distancing if recommended

If the GP is working off site then the patient may request a member of their household is present for the examination. The patient would be responsible for getting the third party to agree to be present and ensuring necessary confidentiality is maintained.

The clinician should be aware of surroundings and whether the video link can be overheard/watched.

In all cases the chaperone should be introduced over the video call and the clinician should document the interaction, request for a chaperone and who the chaperone was present

References

GMC Guidance on Intimate examinations and Chaperones