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  • 1.  Chaperone Policy

    Posted 01-07-2025 08:47

    Good morning, 

    For those ambulatory clinics that have a Chaperone Policy implemented and EPIC, what is your standard work related to documentation?

    Who documents? Staff? Provider?

    What is documented? Offering of chaperone, refusal, use of chaperone...

    Is a progress note used? Smart text?

    Thank you so much!

    Lynn



    ------------------------------
    Lynn D'Angelo DNP RN NEA-BC
    Director, Ambulatory Clinical Excellence
    UMass Memorial Medical Center
    Worcester, MA
    lynn.dangelo@umassmemorial.org
    ------------------------------


  • 2.  RE: Chaperone Policy

    Posted 01-07-2025 09:54

    Hi Lynn,

    I'm not sure if you're in a pediatric or adult environment, but I work in Pediatric Ambulatory Care and I pulled this verbiage from our Chaperone policy (forgive the formatting not pulling over great).

    III. PROCEDURE: 
    A. A chaperone should be present for:
    1. Sensitive examinations 
    2. Any situation where the provider feels a chaperone is warranted 
    3. Any circumstance where the presence of a parent or legal guardian will interfere 
    with the physical examination, such as a possible case of abuse or parental 
    mental health issues
    4. Patient or parent/legal guardian requests a chaperone
    5. Parent or legal guardian is not available or present for physician examination
    B. The use of a chaperone in consultations that may present challenges, conflict or 
    with vulnerable or anxious patients are at the discretion of the provider.
    C. Reasonable efforts should be made to secure a chaperone if one is recommended or 
    requested by a patient or parent/legal guardian. 
    D. Providers are responsible for explaining to the patient, and the parent or legal 
    guardian where applicable, why a physical examination is necessary and how it will 
    be performed. 
    E. The patient and parent/legal guardian shall be provided an opportunity to ask 
    questions so there is no misunderstanding about the reason for the examination or 
    how the examination will be performed.
    F. The patient's wishes should be considered in determining the gender of the 
    chaperone.
    G. Providers should be sensitive to a patient's ethnic, religious and cultural background. 
    This may influence how the examination progresses. 
    H. A provider should not proceed with an examination if he or she thinks the patient or 
    parent/legal guardian does not understand the nature and purpose of the 
    examination due to a language barrier or any other reason. Use of a translator is 
    recommended in such cases.  
    I. Reasonable efforts should be made to provide privacy of physical or psychological 
    aspects of some examination procedures (such as using gowns or drapes to protect 
    privacy)

    J. The chaperone should remain present for the entire examination and in a position to 
    be able to properly observe the procedure. Any variations in the examination should 
    be documented.
    K. It is the responsibility of the provider to accurately document the use or refusal of a 
    chaperone in the medical record, including the name of the chaperone.



    ------------------------------
    BrandyWilliamson, MSN RN CPN
    Director, Ambulatory Nursing, Quality, & Education
    Pediatric SIG Chair
    Children's Healthcare-Atlanta
    Atlanta,GA
    brandy.williamson@choa.org
    ------------------------------



  • 3.  RE: Chaperone Policy

    Posted 01-08-2025 06:54

    EPIC has a section in the rooming tab to document chaperone acceptance or decline as well as who the chaperone is. Patients and providers can request chaperones. In our clinic, nursing documents. We also have signage in the room to educate patients. 



    ------------------------------
    Loren Williams RN AMB-BC
    St Peter's Health Partners
    Saratoga Springs NY
    3154399963
    ------------------------------



  • 4.  RE: Chaperone Policy

    Posted 01-08-2025 10:46
      |   view attached

    Hi Lynn,

    We just did a roll out of a system wide Chaperone Policy. I have been on the workgroups and committees that developed the policy, piloted it, and developed the education. We use EPIC and created a Chaperone form in the activities section, that documents chaperone use/declination in a flowsheet type.

     

    After several months of researching best practices, we found recommendations that the clinician performing the sensitive exam should not the one offering he chaperone or discussing the policy. The majority of our ambulatory sites have the MA or whoever is rooming the patient gather the information and document.

    Happy to jump on a call with you to demo what we do in Epic. Attached our EPIC tip sheet as well.

     

    Lisa

    _____________________

    Lisa C. Dutton, MSN, RN, AMB-BC, NE-BC

    Professional Development Manager, BWH Department of Ambulatory Nursing 

    Co-chair; MGB Ambulatory Nurse Council

    Clinical Director, MGB Nurse Hotline

    Operations Lead, MGB COVID Outpatient Therapies

     

     

    Brigham and Women's Hospital

    75 Francis Street, Boston, MA 02115

    M: 603-479-7468 T: 617-525-7789

    brighamandwomens.org

     

     

     

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