November 22, 2021

Policy now in place formalizes role and use of medical chaperones during patient encounters

Sensitive medical examinations and procedures can create anxiety or an increased sense of vulnerability for patients. Because of this, Vanderbilt University Medical Center has implemented a new policy which standardizes and expands the role of a medical chaperone, an individual who serves as a witness for both a patient and their clinician during a sensitive medical examination or procedure.

The policy went in effect in November for adult and children’s ambulatory clinics, initially excluding those at Vanderbilt Bedford Hospital, Vanderbilt Tullahoma-Harton Hospital and Vanderbilt Wilson County Hospital. The medical chaperone policy will be extended to those locations and to VUMC inpatient settings at a later date. Training for individuals who will serve in the medical chaperone role and their leaders is underway.

“Our staff adheres to high ethical standards, and our goal at VUMC is to always ensure our patients’ safety, while also being mindful of their privacy and dignity,” said Patty Wright, MD, Chief of Staff for Adult Ambulatory Services for Davidson County. “We know that physical examinations and procedures can cause anxiety for any patient, and potentially for their family members or their caregiver. It’s our job to provide a safe, comfortable environment for our patients, and the consistent provision of a trained medical chaperone, particularly during sensitive exams and procedures, supports this effort.”

A sensitive exam or procedure is defined as one which involves the genital, rectal, female breast and/or pelvic areas. Medical chaperones observe the exam or procedure, provide assistance to the clinician if qualified and requested to do so, and if they observe anything that is possibly inappropriate, report this to their immediate supervisor.

Trained medical chaperones will be automatically provided to patients undergoing a sensitive examination or procedure, or a medical chaperone can be requested by either a patient or clinician for any examination or procedure. An adult patient who has the capacity to give informed consent has the right to decline a medical chaperone during a sensitive exam or procedure, but their clinician is not required to proceed if they don’t feel comfortable continuing without a medical chaperone.

“We have used medical chaperones in various clinical settings at Vanderbilt University Medical Center for many years,” said Janice Smith, vice president for Adult Ambulatory Operations. “It’s important to note that while we have a renewed emphasis on this topic, there was no event that led to the development of this policy. This proactive adoption standardizes an important role throughout the organization. The presence of medical chaperones speaks to the organization’s desire to provide an optimal patient experience and a supportive work environment for our clinicians.”

A medical chaperone can be a medical health professional such as a medical doctor who is a member of the VUMC staff, resident, fellow, advanced practice nurse, licensed nurse, technician, therapist or athletic trainer; or an unlicensed staff member who has completed VUMC medical chaperone training. A family member, parent or legal guardian can serve as a medical chaperone in limited and specific circumstances for patients up to 10 years of age.

“We know even the most routine medical care can be stressful for a child and their family or their caregiver,” said Kathy Moss, MSN, MBA, RN, administrative director of Ambulatory Nursing at Monroe Carell Jr. Children’s Hospital at Vanderbilt. “One way to reduce that stress and better protect those who trust us to provide safe and comfortable care is by having a medical chaperone in the room, especially during sensitive exams or procedures. Medical chaperones provide an extra set of eyes and ears to support and reassure everyone involved.”

Policy No. OP 20-10.32 includes a complete list of VUMC staff members who can act as medical chaperones, the definition of a sensitive exam or procedure, what exams or procedures are exceptions to that definition, the process to follow for a patient encounter witnessed by a medical chaperone and how alleged inappropriate activity should be reported.

The policy is found in the Clinical Operations category of the VUMC Policies in PolicyTech.

For more information on VUMC’s medical chaperone policy, including frequently asked questions, please visit: