Use of Chaperones During the Physical Examination of the Pediatric Patient

An appropriate physical examination is usually a critical component of a visit to a pediatrician by an infant, child, adolescent, or young adult and represents efficient, sensitive, and effective health care. The extent of the physical examination is determined by both the reason for the visit and diagnostic considerations raised during the taking of the history.

The purpose and scope of the physical examination should be made clear to the parents as well as the patient if he or she is old enough to understand. If any part of the examination may be physically or psychologically uncomfortable, every effort should be made to support the patient and parent, including the use of measures to preserve privacy, such as gowns and drapes.

In the medical office setting, the physical examination of an infant, toddler, or child should always be performed in the presence of a parent or guardian. If a parent or guardian is 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, a chaperone should be present during the physical examination.

If the patient is an adolescent or young adult and the examination requires inspection or palpation of anorectal or genital areas and/or the female breast, a chaperone is recommended. The presence of a chaperone may be useful to reinforce the professional nature of the interaction and content of the examination and to provide a witness in case of misunderstanding.¹  In general, it is wise for male clinicians to have a chaperone during female breast, anorectal, and genital examinations. However, even same-sex examinations can be misunderstood and can benefit from chaperoning. The patient's wishes and comfort should determine the sex of the chaperone.²  If the patient chooses to have a chaperone, the chaperone should preferably be a nurse or medical assistant. Family members or friends should not be used as chaperones unless specifically requested by the patient and, if at all possible, only in the presence of an additional chaperone who is not a family member or friend.³  The name of the chaperone should be documented in the medical record.

The patient or physician might consider the presence of a chaperone problematic in a variety of circumstances. A patient may feel that his or her privacy and confidentiality may be compromised. A patient may experience embarrassment and increased vulnerability with another party present during the examination. Pediatricians could have concerns that providing a chaperone would require additional staff or that they would not have a chaperone of the desired gender available. In these situations, the use of a chaperone may not be possible.

The use of a chaperone should be a shared decision between the patient and physician. The patient's preference should be given the highest priority when deciding on the use of a chaperone.^4,–,7  If the patient declines the use of a chaperone, the pediatrician should document this fact in the medical record. Regardless of whether a chaperone is used, the physician should review the scope and findings of the examination with the patient and parents at completion of the examination. This review should be documented in the medical record.

In certain situations, a physician may request the presence of a chaperone, particularly when a patient or parent is exhibiting mental health issues; has developmental issues; or displays anxiety, tension, or reluctance toward examination. If the explanation of the scope and confidentiality of the examination does not resolve the tension or conflict, the use of a chaperone during the examination is appropriate.⁸  The pediatrician needs to communicate with the patient and parent why a chaperone is required in this situation. For the rare situation in which the patient refuses an appropriate chaperone and the physician is concerned that providing the examination might result in false allegations or medicolegal risk, the physician is not obligated to provide further treatment.⁹  If a patient request for a chaperone is not able to be accommodated, the patient may refuse to receive further treatment. If care is not provided, the physician must discuss with the patient the risks of not receiving further care and offer alternatives, including being examined by another provider or seeking care elsewhere. This discussion should be documented in the medical record.

Pediatricians should develop and follow a clear policy for the office or clinic setting regarding the presence of a chaperone during parts of the physical examination. This policy should include respect for privacy and confidentiality by the chaperone.¹⁰  Pediatricians should document in the medical record if they are unable to adhere to the policy or state medical board regulations regarding the use of a chaperone.

1. Communication in advance regarding the components of the physical examination is of critical importance. Effective communication will help ensure that there is no misunderstanding about the reasons for and conduct of the examination.

2. If the patient is an adolescent or young adult and the examination requires inspection or palpation of anorectal or genital areas and/or the female breast, a chaperone is recommended. However, the use of a chaperone should be a shared decision between the patient and physician.

3. If a medical chaperone is indicated and the patient refuses, the patient or parent should be given alternatives, including seeking care elsewhere.

4. Pediatricians should develop policy about the use of chaperones in the office or clinic setting and document in the medical record if they are unable to adhere to the policy or state medical board regulations.

Edward S. Curry, MD

Lawrence D. Hammer, MD, Chairperson

Oscar W. Brown, MD

Edward S. Curry, MD

James J. Laughlin, MD

Herschel R. Lessin, MD

Geoffrey R. Simon, MD

Chadwick T. Rodgers, MD

Elizabeth Sobczyk, MPH, MSW