UNIVERSITY OF WISCONSIN MEDICAL FOUNDATION
CLINICAL POLICY AND PROCEDURE
TITLE: Guidelines for Chaperones for Sensitive Exams
Effective Date: February, 2011 Approval: Clinical Staff Education
Reviewed October, 2011 February, 2014
PURPOSE: To provide guiding principles for offering and documenting the presence of chaperones for
patients undergoing sensitive exams including, but not limited to pelvic exams, breast exams,
catheterization, or any exam of male or female genitals.
POLICY: UWMF/DFM clinicians who need to provide sensitive exams on patient, regardless of gender or
age, are encouraged to offer a chaperone to accompany them throughout the exam. The offer and response
of the patient should be documented in the patient’s record.
1. If the patient would like to have a family member or primary support person accompany them
through a sensitive exam, the family member or primary support person shall be allowed.
Document the presence of the family member as the chaperone in the clinical note.
In the case of procedural areas where space may be limited or sterile fields are of
concern, a health care member may be substituted for the primary support person as clinics can
It is not appropriate to allow a family member to be present during the exam in cases in
which domestic abuse is suspected. In these situations, the provider should request that the family
member leave and offer a staff chaperone.
2. If the patient does not want a family member or primary support person to be present for the
sensitive exam, but would like a chaperone present, a clinic staff member shall be offered.
If a staff member is not available and the exam can be deferred until one is available, that
option should be made available to the patient. If the exam is of a time sensitive nature, every
effort should be made to make a chaperone available.
3. If the clinician is uncomfortable with providing a sensitive exam on his/her own, it is acceptable
for the clinician to ask that a chaperone be present. If a chaperone is not available, the clinician
may defer the exam until a chaperone is able to be present.
4. Document in the clinical note using Health Link smart phrase .chaperone, to include: That a
chaperone was offered, the patient's response to the offer, and who, if anyone, was present as the
chaperone. If a staff member is utilized as the chaperone, document the staff member's name and
WRITTEN BY: Ronnie Peterson, R.N., M.S., Manager of Clinical Support
REVIEWED BY: Teri Helmke, CSW, Patient Resources Director
AUTHORIZED BY: Richard Welnick, MD, Medical Director, Ambulatory Clinic Operations, UWMF
Sandra A. Kamnetz M.D., Vice Chair, Department of Family Medicine
Medical Director, UWMF Date
Vice Chair, Department of Family Medicine Date