June 1, 2022

Medical chaperone policy extends to VUMC’s inpatient areas

VUMC’s medical chaperone policy has been extended to inpatient settings, including Vanderbilt University Hospital, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Vanderbilt Psychiatric Hospital, Vanderbilt Bedford Hospital, Vanderbilt Tullahoma-Harton Hospital and Vanderbilt Wilson County Hospital.


by Jill Clendening

Sensitive medical examinations and procedures can sometimes cause patients to feel vulnerable or anxious. Because of this, Vanderbilt University Medical Center implemented a policy in 2021 which standardized the role of a medical chaperone, an individual who serves as a witness for both a patient and the clinician during a sensitive medical examination or procedure.

The policy was first implemented in adult and children’s ambulatory clinics across the Vanderbilt Health system, with employees serving as medical chaperones receiving specialized training before stepping into the role. As of June 1, the medical chaperone policy was extended to VUMC’s inpatient settings, including Vanderbilt University Hospital, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Vanderbilt Psychiatric Hospital, Vanderbilt Bedford Hospital, Vanderbilt Tullahoma-Harton Hospital and Vanderbilt Wilson County Hospital.

“Medical chaperones have been available and in use in various clinical settings at VUMC for many years. This policy was not developed in response to any event at VUMC,” said C. Wright Pinson, MBA, MD, Deputy CEO and Chief Health System Officer. “The medical chaperone policy proactively ensures patients and providers alike are safeguarded when sensitive exams are medically indicated. Having this policy formalized and in place fosters a supportive environment for chaperones.”

A sensitive examination or procedure for which a medical chaperone would be present is defined as one which involves the genital, rectal, developed breast tissue and/or pelvic areas. A medical chaperone is also required for any photography of developed breast tissue, genitalia or rectum used for documentation in the medical record.

Medical chaperones observe the exam or procedure and can provide assistance to the clinician if qualified and requested to do so. If they observe anything that is possibly inappropriate, they are required to report this to the area manager and to the VUMC Office of Risk and Insurance Management.

“Our patients and their families are our top priority at Vanderbilt University Medical Center, and we are committed to their safety and peace of mind,” said Executive Chief Nursing Officer Marilyn Dubree, MSN, RN, NE-BC. “The expansion of this policy to provide trained medical chaperones in our inpatient care locations is an important example of this.

“Representatives from every hospital worked together to create a policy that could be effectively implemented in our inpatient settings. Thoughtful input from the VUMC Office of Diversity and Inclusion also ensured the policy is sensitive to and accommodates the needs of all patients.”

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 believe the use of medical chaperones is best practice to protect our patients and our clinicians,” said Sandy Bledsoe, Vice President of Risk Management for VUMC. “Our plan all along was for the medical chaperone policy to be implemented throughout the enterprise. We began with the ambulatory space because we knew Women’s Health had already been doing this for a long time; they served as a model for how this could be done. We also took what we learned from the implementation in the ambulatory space to guide the logistics of expanding the policy into the inpatient spaces.”

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, physician assistant, 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 are thankful for the many leaders and committees representing all of our hospitals who collaborated to create recommendations for modifying the original medical chaperone policy and associated standard operating procedure to reflect the inpatient environments,” said Jay Morrison, MSN, RN, senior associate of Nursing for Vanderbilt University Hospital. “And we’re grateful to those who are serving as medical chaperones. As of May 19, 80% or 10,754 employees of the 13,463 assigned this role, have completed their medical chaperone training.”

The medical chaperone policy includes a complete list of VUMC employees 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 medical chaperone policy and correlating SOP are found in the Clinical Operations category of PolicyTech for VUMC’s main campus. A near-identical version of the policy and SOP which have been approved for Vanderbilt Health’s regional hospitals are located on the PolicyTech site for each of those facilities.