36C24218R0169-054.pdf

RFP 36C24218R0169

D.26 CHAPERONE FOR WOMEN’S HEALTH EXAMS (CM 11-60, JANUARY 1, 2017)

VA WESTERN NEW YORK HEALTHCARE SYSTEM

January 1, 2017 CENTER MEMORANDUM NO. 11-60

CHAPERONE FOR WOMEN'S HEALTH EXAMS

1. PURPOSE: To provide high quality services to our female patients, during any health care examination, procedure, or treatment and to witness propriety on the part of the provider.

2. POLICY: To provide high quality services to our female patients, during any health care examination, procedure, or treatment regardless of the gender of the provider, there must be a female chaperone present in the room for the entire exam. A female chaperone must also be present when requested by a female patient for any type of visit/exam/procedure/treatment. This process will ensure consistent high quality customer service practice, privacy and dignity towards the female patient and the provider involved. This policy applies to all department/clinics within the VA Western New York Healthcare System.

3. RESPONSIBILITIES:

(a) For Physical Examinations:

1. A female chaperone must be in the examination room during breast and pelvic exams; and

2. In addition to breast examinations and pelvic examinations, and Pap smears, this includes procedures such as urodynamic testing or treatments such as pelvic floor physical therapy.

(b) For Radiologic Procedures:

1. Mammography does not require a chaperone (all mammography technologists in VA are female);

2. Breast Ultrasound, Breast MRI, Pelvic Ultrasound, Pelvic or Femoral Vascular Ultrasound or any procedure that exposes the groin or pubic area: For the protection of both the patient and the radiologist or technologist, it is highly recommended that male radiologists or technologists have a chaperone present. Female radiologists and technologists should ask female patients if they want a chaperone and provide chaperones on request; and

3. Trans-vaginal ultrasound requires a chaperone regardless of the gender of the radiologist or technologist.

NOTE: In addition to these requirements a radiologist or technologist may request a chaperone for an imaging procedure according to their clinical judgment.

(c) For Electrocardiograms and Echocardiograms:

1. It is highly recommended for protection of both the patient and the RN or technologist that male nurses or technologists have a chaperone present. Female nurses or technologists should ask female patients if they want a chaperone and provide chaperones on request.

2.The following staff may function as female chaperones: MDs, RNs, HTs, LPNs and other clinical personnel such as radiology technologists.

4. PROCEDURES:

a. Female chaperones are provided irrespective of whether the examination is being performed by a male or a female provider.

b. Chaperone provides gown, drape, and other dressing apparel to patient. Privacy curtains are pulled so that patient may dress behind them. Chaperones assist the Veteran with dressing and undressing if needed. If assistance is not needed, chaperone exits the room until patient is gowned/ ready. Patient is alerted to the availability of a lock on the exam door, should the patient choose to use this lock or not.

c. An exam, treatment, or procedure is completed by the provider with a chaperone present at all times in the room when patient has disrobed. The chaperone will use proper draping to shield the intimate body parts during an exam, treatment, or procedure.

d. Chaperones assist patient with re-dressing, if needed; privacy curtains are closed. If assistance is not needed, the chaperone exits the room until patient is dressed/ ready. Patient is alerted to the availability of a lock on the exam door.

e. The provider documents in the patient’s medical record the name of the chaperone present during the exam, procedure, treatment. Following a physical examination, the provider must discuss any positive finding with the patient and provide opportunity for questions. The patient must be fully dressed during this discussion.

f. The patient and provider will never be left alone, even for a short time, if the patient is disrobed.

g. The chaperone will be sensitive to the emotional needs of the patient. The exam, test or procedure may be very personal in nature. The chaperone will adhere to VHA privacy policies.

h. Female patients are informed that it is VA policy for a chaperone to be present. If the patient refuses a chaperone, staff should explore the reason for refusal and try to resolve. If the patient continues to refuse having a chaperone present, the provider may decline to perform the exam, as VA policy is not being followed. The Veteran's refusal of chaperone and attempts to resolve the issue must be completely documented in the patient medical record.

5. REFERENCES: VHA Handbook 1330.01 Health Care Services for Women Veterans, May 21, 2010

6. RESCISSION: Center Memorandum 11-60 dated January 15, 2014

7. FOLLOW-UP RESPONSIBILITY: Chief of Staff (11), Women Veterans Program Manager

8. AUTOMATIC REVIEW DATE: January 1, 2020

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BRIAN G. STILLER

Medical Center Director

DISTRIBUTION: 1 copy each (00, 00QM, Women Veterans Program Manager, Chief of Staff)