Chaperone Policy

Chaperone Policy Poster

1      Introduction

1.1      Policy statement


The purpose of this document is to ensure conformity in order to achieve a good standard of medical practice. This is achieved by enabling the patient to have a chaperone present during the consultation and clinical examination of the patient. Medical examinations can, at times, be perceived as intrusive by the patient, so having a chaperone present protects both the patient and staff member.

1.2      Status


This document and any procedures contained within it are non-contractual and may be modified or withdrawn at any time. For the avoidance of doubt, it does not form part of your contract of employment.

1.3      Training and support


The practice will provide guidance and support to help those to whom it applies understand their rights and responsibilities under this policy. Additional support will be provided to managers and supervisors to enable them to deal more effectively with matters arising from this policy.

2      Scope

2.1      Who it applies to


This document applies to all employees of this practice. Other individuals performing functions in relation to the practice, such as agency workers, locums and contractors, are encouraged to use it.

2.2      Why and how it applies to them


All clinical and trained non-clinical staff, may at some point be asked to act as a chaperone at St Peter’s Medical Centre.  Therefore, it is essential that these employees are fully aware of their individual responsibilities when performing chaperone duties.


The practice aims to design and implement policies and procedures that meet the diverse needs of our service and workforce, ensuring that none are placed at a disadvantage over others, in accordance with the Equality Act 2010. Consideration has been given to the impact this policy might have in regard to the individual protected characteristics of those to whom it applies.

3      Definition of terms

3.1      Chaperone


A chaperone can be defined as:

  • An independent person, appropriately trained, whose role is to independently observe the examination/procedure undertaken by the doctor/health professional to assist the appropriate doctor-patient relationship’.[1]

4      Policy

4.1      Raising patient awareness


At St Peter’s Medical Centre, the chaperone policy is clearly displayed in the waiting area (see Chaperone Policy Poster, in all clinical areas, and annotated in the practice leaflet as well as on the practice website. All patients should routinely be offered a chaperone, ideally at the time of booking the appointment. The importance of a chaperone should not be underestimated or understated.

4.2      Personnel authorised to act as chaperones


It is practice policy that only clinical staff act as chaperones as it is expected that such staff will have familiarity with the procedure or examination the patient is undergoing. Alternatively, we have other employees who have received the appropriate chaperone training. If a chaperone is not available, the examination should be postponed until a suitable chaperone is present.


Patients must be advised that a family member or friend is not permitted to act as a chaperone as they have not received the requisite training, nor do they have the clinical knowledge required. However, they may be present during the procedure/examination if the patient is content with this decision.

4.3      General guidance


It may be appropriate to offer a chaperone for a number of reasons. All clinicians should consider using a chaperone for some or all of the consultation and not solely for the purpose of intimate examinations or procedures. This applies whether the clinician is of the same gender as the patient or not.


Before conducting any intimate examination, the clinician should:[2]


  • Explain to the patient why an examination is necessary and give the patient an opportunity to ask questions
  • Explain what the examination will involve, in a way the patient can understand, so that the patient has a clear idea of what to expect, including any pain or discomfort
  • Get the patient’s consent before the examination and record that the patient has given it
  • Offer the patient a chaperone
  • Give the patient privacy to undress and dress, and keep them covered as much as possible to maintain their dignity; do not help the patient to remove clothing unless they have asked you to do so, or you have checked with them that they want you to help
  • If the patient is a young person or child, you must:
    • Assess their capacity to consent to the examination
    • If they lack capacity, seek parental consent


Ensuring that the patient fully understands the why, what and how of the examination process should mitigate the potential for confusion.


4.4      Competencies and training


Chaperones should undergo training which enables them to understand:


  • What is meant by the term ‘chaperone’
  • A knowledge of the range of examinations or procedures they may be expected to witness. Alternatively, for those who are non-clinical, an explanation from the attending clinician of the procedure about to be performed and why.
  • Why they need to be present, including positioning
  • Their role and responsibilities as a chaperone
  • How to raise concerns in conjunction with practice policy
  • The rights of the patient
  • The requirement to annotate their presence on the individual’s healthcare record post consultation


Training will be undertaken by all staff who may be required to act as a chaperone at St Peter’s Medical Centre. Training is provided in-house via BlueStream or locally by the CCG or HHCIC.

4.5      Considerations


In a diverse multicultural society, it is important to acknowledge the spiritual, social and cultural factors associated with the patient population. Clinicians must respect the patient’s wishes and where appropriate refer them to another practitioner to have the examination or procedure undertaken.


Local guidance should be sought regarding patients suffering from mental illness or those with learning difficulties. A relative or carer will prove to be a valuable adjunct to a chaperone.



4.6      Confidentiality


Chaperones are to ensure that they adhere to the practice Caldicott and Information Governance Policies. The clinician carrying out the examination or procedure should reassure the patient that all clinical and trained non clinical staff within the practice fully understands their obligation to maintain confidentiality at all times.

4.7      Practice procedure (including read codes)


If a chaperone was not requested at the time of booking the appointment, the clinician will:


  • Offer the patient a chaperone, explaining the requirement (read code 9NP0), and if the patient agrees:
  • Contact reception and request a chaperone
  • Record in the individual’s healthcare record that a chaperone is present and identify them (read code 9NP1)
  • The chaperone should be introduced to the patient
  • The chaperone should assist as required, but maintain a position so that they are able to witness the procedure/examination (usually at the head end)
  • The chaperone should adhere to their role at all times
  • Post procedure or examination, ensure they annotate in the patient’s healthcare record that they were present during the examination and there were no issues observed
  • The clinician will annotate in the individual’s healthcare record the full details of the procedure as per current medical records policy


Should an individual refuse to have a chaperone present, this is also to be annotated using the read code 9NP2. If, for reasons beyond the control of the clinician, there are no chaperones available, this should also be recorded using the read code 9NP4.

4.8      Chaperoning visitors and guests (including VIPs)


There may be, on occasion, a need to ensure that appropriate measures are in place to chaperone visitors and guests including Very Important People (VIPs). St Peter’s Medical Centre will follow the recommendations outlined in the Lampard Report (2015) and will:


  • Ensure that any visitors are escorted by a permanent member of staff at all times throughout the duration of their visit
  • The individual organising the visit must arrange for a suitable member of staff to act as a chaperone. Furthermore, the reason for the visit must be documented, giving details of the areas to be visited and if patients are to be contacted during the visit
  • The chaperone is to ensure that no visitors enter clinical areas where there may be intimate examinations or procedures taking place; this protects and promotes the privacy, dignity and respect of patients
  • The person arranging the visit must ensure that there is sufficient time for the practice team to advise patients of the visit and offer patients the opportunity to decline to interact with the visitor(s)
  • Given the diverse nature of the patient population, some patients may not understand or may become confused as to why visitors or guests (including VIPs) are present. To minimise any confusion or distress, such patients as well as the visitor(s) are to be offered a chaperone
  • The person arranging the visit must ensure that the visitor(s) has produced photographic ID prior to the visit taking place
  • The chaperone is to accept responsibility for the visitor(s) at all times. They must also be prepared to challenge any unacceptable or inappropriate behaviour, reporting such incidences to the Practice Manager immediately
  • The chaperone must ensure that no patient records or other patient-identifiable information is disclosed to the visitor(s). Chaperones are to ensure that the visitor(s) is aware of the need to retain confidentiality should they overhear clinical information being discussed. Any breaches of confidentiality are to be reported immediately to the Practice Manager.
  • If media interest is likely, the chaperone is to inform Harrow CCG, requesting that the communication team provides guidance
  • Under no circumstances is the chaperone to leave the visitor(s) alone with any patient or patient-identifiable information; this is to ensure that both the patient and visitor(s) are appropriately protected

4.9        Summary


The relationship between the clinician and patient is based on trust, and chaperones are a safeguard for both parties at St Peter’s Medical Centre. The role of a chaperone is vital in maintaining a good standard of practice during consultations and examinations. Regular training for staff and raising patient awareness will ensure that this policy is maintained.

[1] Definition of a Chaperone

[2] Intimate Examinations and Chaperones: Guidance