Lepton & Kirkheaton Surgeries
Chaperone Policy and Practice Training Programme
For Staff
CONTENTS
Chaperone Policy for our Patients- published on our website
and available in our waiting rooms.
Guidance from the General Medical Council regarding
Intimate examinations and chaperones-April 2013
Overview fact sheet from The Medical Protection Society
about Chaperones-July 2014
Key points to remember regarding Chaperoning
Chaperoning- practical aspects for our Staff
Why bother and why now? The Ayling Report
When to use chaperones
Which examinations?
What to do when patients decline a chaperone
Home visits
Who should chaperone?
Communication
Requirements for intimate examinations
Training for chaperones
o What is your role?
o What should you expect to happen?
o When should you leave?
o What type of examinations may you be asked to
witness and what happens in each?
o Breast examination
o Female Pelvic/Vaginal examination
o Rectal examination
o Male genital examination
Chaperone Poster for waiting rooms and above couches
References
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This policy should be read in conjunction with viewing the DVD on
Chaperones as issued by the GHCCG in August 2014.
Created by Dr Saheli Chaudhury-August 2014
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Chaperone Policy for our Patients
You can also find this information on our website
www.lepton-kirkheatonsurgeries.nhs.uk
What to expect:
Lepton and Kirkheaton Surgeries as a Practice are committed to
providing a safe and comfortable environment where patients and staff
can be confident that “Best Practice” guidance as recommended by The
General Medical Council of the United Kingdom is being followed at all
times. We recognise that we have an obligation to respect the dignity of
each patient and to conduct each consultation in a manner that strives to
provide a comfortable, confidential, private and safe environment.
What is a Formal Chaperone?
 Witness
 Support
 Safeguard
In clinical medicine, a formal chaperone is a person who acts as a:
 Witness for both a patient and a clinician/health care professional
usually a doctor or nurse.
 Support providing comfort and reassurance to the patient and
verifies continued consent to the examination or medical
procedure.
 Safeguard for both parties during a medical examination or
procedure and is a witness to continuing consent of the procedure
which is turn safeguards the Practice against formal complaints or
legal action.
A friend or relative of the patient is NOT an impartial observer, and so
CANNOT act as a formal chaperone but should be allowed to stay if the
patient so wishes.
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Why do we need Chaperones?
There are two main considerations involved in having a chaperone to
assist during intimate examinations;
1. To offer support and comfort to the patient
2. The protection of the doctor or nurse from allegations of impropriety.
The following groups or situations are when the need for a chaperone can
commonly arise:
 Vulnerable adults
 Anyone requiring an intimate examination
 Under 16s attending alone
 ‘At risk’ patients
 Unknown patients new to the list
 Examination at close proximity
What is an intimate examination?
Usually considered to be an examination of any part of the body between
the collar bones and the knee. Obvious examples of an intimate
examination include examinations of the breasts, genitalia and the
rectum.
However, some patients may be uncomfortable with examinations at
close proximity for example conducting eye examinations in dimmed
lighting.
Parents can give consent for the new born or six week baby check where
the baby has to be fully undressed.
The rights of the Patient:
All patients are entitled to have a chaperone present for any consultation,
examination or procedure where they feel one is required.
Patients have the right to decline the offer of a chaperone. However the
clinician may feel that it would be wise to have a chaperone present for
their mutual protection for example, an intimate examination on a young
adult of the opposite gender.
If the patient still declines the doctor will need to decide whether or not
they are happy to proceed in the absence of a chaperone. This will be a
decision based on both clinical need and the requirement for protection
against any potential allegations of improper conduct.
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Appropriately Trained Chaperone:
Appropriately trained Chaperone is defined as a member of our Practice
staff who has completed the Practice Training Programme.
If an intimate examination is required, the clinician will:
 Establish there is a need for an intimate examination and discuss
this with the patient.
 Give the patient the opportunity to ask questions.
 Obtain and record the patient’s consent.
 Offer a chaperone to all patients for intimate examinations (or
examinations which may be construed as such).
If the patient does not want a chaperone it will be recorded in the
notes.
The Patient can expect the chaperone to be:
 Available if requested.
 Pleasant, approachable, professional in manner and to be able to
put them at ease.
 Clean and presentable.
 Confidential.
Where will the chaperone stand? What will they do?
The positioning of the chaperone will depend on several factors for
example the nature of the examination and whether or not the chaperone
has to help the clinician with the procedure. The clinician will explain to
you what the chaperone will be doing and where they shall be in the
room. During the time that a chaperone is present, the doctor or nurse will
strive to keep all enquiries of a sensitive nature to a minimum.
The clinician will document and record the name of the chaperone in your
medical notes.
When a chaperone is not available:
There may be occasions when a chaperone is unavailable, for example on
a home visit, then in such circumstances the doctor will assess the
circumstances and decide if it is appropriate to go ahead without one or
rearrange another date for examination with a chaperone present.
Should you have a concern about a chaperone:
Patients should please raise any concerns about a chaperone to a GP
Partner or the Practice Manager. If you wish to make a complaint please
do so in writing via the Practice’s usual comments/complaints procedure.
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Guidance from The General Medical Council (GMC) regarding
Intimate examinations and Chaperones- April 2013
The GMC brought out new guidance in April 2013 regarding Intimate
examinations and chaperones. Chaperones should be familiar with the
adapted guidance below:
When an intimate examination is to be performed, we should offer the
patient the option of having an impartial observer (a chaperone) present
wherever possible. This applies whether or not you are the same gender
as the patient.
A chaperone should usually be a health professional and but a chaperone
should:
a) be sensitive and respect the patient’s dignity and confidentiality
b) reassure the patient if they show signs of distress or discomfort
c) be familiar with the procedures involved in a routine intimate
examination
d) stay for the whole examination and be able
e) to see what the doctor is doing, if practical
f) be prepared to raise concerns if they are concerned about the
doctor’s behaviour or actions.
A relative or friend of the patient is not an impartial observer and so
would not usually be a suitable chaperone, but you should comply with a
reasonable request to have such a person present as well as a chaperone.
If either the doctor or the patient does not want the examination to go
ahead without a chaperone present, or if either of them is uncomfortable
with the choice of chaperone, you may offer to delay the examination to a
later date when a suitable chaperone will be available, as long as the
delay would not adversely affect the patient’s health.
If the doctor does not want to go ahead without a chaperone present but
the patient has said no to having one, the doctor must explain clearly why
you want a chaperone present. Ultimately the patient’s clinical needs
must take precedence. You may wish to consider referring the patient to a
colleague who would be willing to examine them without a chaperone, as
long as a delay would not adversely affect the patient’s health.
You should record any discussion about chaperones and the outcome in
the patient’s medical record. If a chaperone is present, you should record
that fact and make a note of their identity. If the patient does not want a
chaperone, you should record that the offer was made and declined.
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Overview factsheet from The Medical Protection Society about
Chaperones -July 2014
Regardless of the patient’s role, the guidelines from medical regulatory
bodies are clear: it is always the doctor’s responsibility to manage and
maintain professional boundaries – utilising chaperones effectively is a
way of managing relations with patients, where the ultimate responsibility
for ensuring that relations remain on professional footing rests with you.
Background
In 2004 the Committee of Inquiry looked at the role and use of
chaperones, following its report into the conduct of Dr Clifford Ayling. It
made the following recommendations:
 Each trust should have its own chaperone policy and this should be
made available to patients.
 An identified managerial lead (with appropriate training).
 Family members or friends should not undertake the chaperoning
role.
 The presence of a chaperone must be the clear expressed choice of
the patient; patients also have the right to decline a chaperone.
 Chaperones should receive training.
Why use chaperones?
 Their presence adds a layer of protection for a doctor; it is very rare
for a doctor to receive an allegation of assault if they have a
chaperone present.
 To acknowledge a patient’s vulnerability.
 Provides emotional comfort and reassurance.
 Assists in the examination.
 Assists with undressing patients.
 Enables them to act as an interpreter.
What is an intimate examination?
Obvious examples include examinations of the breasts, genitalia and the
rectum, but it also extends to any examination where it is necessary to
touch or be close to the patient; for example, conducting eye
examinations in dimmed lighting, taking the blood pressure
cuff, palpitating the apex beat. Consult GMC and NMC advice on
intimate examinations (see further information).
How to develop a chaperone policy
Here is a useful checklist for the management of a consultation:
 Establish there is a need for an intimate examination and discuss
this with the patient.
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Explain why an examination is necessary and give the opportunity
to ask questions; obtain and record the patient’s consent.
Offer a chaperone to all patients for intimate examinations (or
examinations that may be construed as such). If the patient does not
want a chaperone, record this in the notes.
If the patient declines a chaperone and as a doctor you would prefer
to have one, explain to the patient that you would prefer to have a
chaperone present and, with the patient’s agreement, arrange for a
chaperone. If the patient continues to decline a chaperone, consider
transferring their care to an available colleague who would be
willing to examine them without a chaperone. Ultimately, the
patient's clinical needs must take precedence, and such
arrangements must not cause a delay that would adversely affect
the patient's health.
Be aware and respect cultural differences. Religious beliefs may
also have a bearing on the patient’s decision over whether to have a
chaperone present.
Give the patient privacy to undress and dress. Use paper drapes
where possible to maintain dignity.
Explain what you are doing at each stage of the examination, the
outcome when it is complete and what you propose to do next.
Keep the discussion relevant and avoid personal comments.
Record the identity of the chaperone in the patient’s notes.
Record any other relevant issues or concerns immediately after the
consultation.
In addition, keep the presence of the chaperone to the minimum
necessary period. There is no need for them to be present for any
subsequent discussion of the patient’s condition or treatment.
Written information detailing the policy should be provided for patients,
either on the practice website or in the form of a leaflet.
Where should the chaperone stand?
Exactly where the chaperone stands is not of major importance, as long as
they are able to properly observe the procedure so as to be a reliable
witness about what happened.
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Key points to remember regarding Chaperoning:
 Inform your patients of the practice’s chaperone policy.
 Record and document clearly the use, offer and declining
of a chaperone in the patient’s notes.
 Ensure training for all chaperones.
 Be sensitive to a patient’s ethnic/religious and cultural
background. The patient may have a cultural dislike to
being touched by a man or undressing.
 Do not proceed with an examination if you feel the patient
has not understood due to a language barrier
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Chaperoning- Practical Aspects for our Staff
A chaperone should:
1. Make themselves available as soon as practicable to assist in
an examination or make clear to the doctor when they expect
to be available. This is to avoid any undue delay while the
patient may be partially undressed which may increase
patient’s anxiety which may already be heightened before an
intimate examination. . If you recognise the identity of the
patient, inform the doctor who may offer the patient the
option of another chaperone or postponing the examination
to another time.
2. You should allow the patient sufficient time and privacy to
undress. Assist if absolutely necessary. Please ensure the
patient has been given a “MODESTY SHEET”.
3. Ask the patient’s permission to enter inside the curtain and
be sensitive in protecting their dignity prior to the
examination. The doctor themselves may ask their
permission to enter first and then you may both enter
together.
4. Introduce yourself to the patient, by name and inform them
of your role.
5. You should verify the patient’s understanding of the type of
examination i.e. breast, anal, vaginal or breast. This is to
open channels of communication between the chaperone and
patient to enable the chaperone to provide emotional comfort
and reassurance. It may be difficult for a patient to convey
doubt or distress to a chaperone if the chaperone appears
silent and unapproachable.
6. It is important to minimise personal discussions with the
patient during the examination and if possible avoid
commenting on confidential medical or social issues during
this time. However, if you feel the patient requires
information in order to proceed with the examination either
alert the doctor or offer an explanation to the patient.
7. Assist the doctor in positioning the patient if required and
stand where appropriate for the necessary examination often
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at the head end of the bed to observe for any signs of distress
or discomfort of the patient.
8. If any undue discomfort is noticed, it is important to
recognise that the doctor may not be aware of this while he
or she is focussed on other aspects of the examination. The
chaperone should therefore ask the patient, ‘Is that
uncomfortable for you? ‘to alert the doctor to any distress
and allow the patient to communicate this. Provide
reassurance if the patient wishes to continue. If there is any
doubt as to whether the doctor has appreciated your concern,
then please be more explicit if required.
9. If undue discomfort or distress occurs at this time or any
other, the patient should be asked, ‘Do you want the doctor
to go no further?’ The patient’s request to stop should
always be respected.
10.Please consider patient confidentiality during discussions
between the doctor and patient regarding medical conditions
which should preferably be delayed until after the chaperone
has departed.
11.If you have concerns following an examination, please
contact the practice manager as soon as possible following
the examination or if you require clarification over a certain
aspect of the examination, please ask the doctor concerned in
a private and confidential manner.
12.Rarely, a patient may insist that a chaperone is not present
during an intimate examination. On these occasions it may
be necessary for a doctor to ask an impartial witness such as
a receptionist or nurse, to verify that the patient insists that a
chaperone is not present even though it has been suggested
by the doctor. Even in these circumstances, if a doctor does
not wish to go ahead with an examination, then he or she is
not obliged to e.g. with a patient who may not be competent
to consent to an intimate examination or if a suspicion of
undue coercion exists.
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CHAPERONES:
Why bother, and why now?
 For any health professional an accusation of inappropriate
behaviour towards a patient is devastating and the consequences
can be far reaching. Cases can take many months, and often years,
to resolve, by which time the doctor concerned may have been
through criminal, civil, and regulatory authority proceedings as
well as facing adverse publicity in the media.
 The presence of a chaperone can often protect both the doctor and
the patient from potential allegations.
 The Ayling report, published in September 2004, after Clifford
Ayling, a general practitioner from Folkestone, Kent was convicted
of 13 counts of indecent assault on female patients, was the result
of an independent inquiry into the way that the NHS dealt with
allegations about the conduct of Clifford Ayling and it highlighted
the issue of chaperones.
 The report found a lack of common understanding of the purpose
and use of chaperones across the NHS. It found that chaperones
were used in various settings and circumstances with differing
levels of risk to patients and healthcare professionals
 It recommended that:
o Trained chaperones should be available to all patients having
intimate examinations. Untrained administrative staff or
family or friends of the patient should not be expected to act
as chaperones
o The presence of a chaperone must be the patient's choice and
they must be able to decline a chaperone if they wish
o All NHS trusts need to set out a clear chaperone policy and
should ensure that patients are aware of it and that it is
adequately funded. The report recognised that for primary
care a policy will have to take into account issues such as
one to one consultations in patients' homes and the capacity
of practices to meet the requirements of an agreed policy
When to use chaperones
Chaperones:
 Safeguard the patient against abuse during examination. Great
emphasis is given to the role of the chaperone in protecting the
patient against sexual abuse though this is probably very rare.
 Can protect the patient against other forms of real or perceived
abuse. The presence of a chaperone acts as a safeguard against a
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doctor causing unnecessary discomfort, pain, humiliation or
intimidation during examination.
May provide reassurance to an anxious patient.
Can inform the doctor of the patient’s discomfort, if on occasions
when the doctor’s attention is focused on performing the
examination. The chaperone can maintain communication and eye
contact with the patient.
May assist an infirm or disabled patient with dressing and
undressing.
Protects doctors against false allegations of sexual abuse.
There are theoretical disadvantages of a chaperone being present during a
gynaecological examination. Gynaecological consultations occasionally
provide an opportunity for women to confide deeply sensitive
information about sexual abuse, previous termination of pregnancy or
domestic violence. The presence of a chaperone may intrude in a
confiding doctor–patient relationship and may lower a doctor’s alertness
to detecting non-verbal signs of distress from the patient. This drawback
is potentially offset by confining the presence of chaperones to the
physical examination and allowing one-to-one communication for the
consultation. Clearly levels of embarrassment may increase in proportion
to the number of individuals present during an examination.
Which Examinations?
 The General Medical Council and the Medical Protection Society
advise that when doctors have to carry out intimate examinations—
those of the breast, genitalia, or rectum—they should always offer a
chaperone.
 If there are not enough staff to provide one you should not proceed
if you have concerns. Postponing an examination because there is
no chaperone is acceptable unless it is an emergency.
 Chaperones are advised whether the patient is the same sex and the
clinician or not. A a female GP received a complaint from a female
patient, though it was withdrawn some months later.
 It is not just intimate examinations that cause problems, and you
should trust your instincts before performing any examination. If
you are worried or the patient seems unduly reluctant to be
examined, arrange for a chaperone or refer the patient to a
colleague. A patient's cultural and religious beliefs should also be
taken into account when considering a chaperone
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 Adolescent patients generally have a lower embarrassment
threshold and so a chaperone may be used in situations where you
would not usually use one.
Many patients feel that the presence of a third party during an intimate
examination is intrusive and embarrassing. Patients have the right to
decline a chaperone and you should not make them feel obliged to accept
one. If a chaperone is offered and declined, make a note of this is in the
patient's records with any relevant discussion. One American healthcare
provider http://www.healthcaresouth.com/pages/chaperone.htm publishes
its chaperone policy and attempts to reduce patient concern with the
statement ‘the health care provider will strive to keep all inquiries of a
sensitive nature to a minimum’ [when the chaperone is present].
When a chaperone is used it should be recorded in the notes their name
and position. If a complaint is made at a later date it is unlikely that you
will remember who was present at the examination.
What do when patients decline a chaperone?
The Ayling report recognised a patient's right to decline a chaperone. It
also acknowledged that a chaperone may not always be available. As a
result there are no cast iron rules governing their use, and it is often a
question of using your professional judgment to assess an individual
situation.
Record in the notes that you have offered a chaperone and it has been
declined
However, you also have the right to protect yourself, and if you do not
want to proceed with an examination without a chaperone explain this and
ask the patient to change his or her mind or accept referral to another
doctor.
Many patients feel that a request for a chaperone is a reflection on them
and that you think they are not trustworthy. If you decline to perform an
examination because there is no chaperone you should explain that it is
for practical reasons.
Home visits
If an intimate examination is required in a patient who cannot attend the
surgery, unless the examination is needed urgently, it should be
postponed until a chaperone is available. This should be explained to the
patient and only if the patient declines the presence of a chaperone and
the clinician is comfortable to proceed should they do s
Who should chaperone?
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While some patients may welcome the presence of a family member
acting as chaperone, there are potential disadvantages. The presence of a
family member may reduce the likelihood of disclosure of sensitive
information and delay the development of self-confidence in young
women. The presence of a dominant male partner may inhibit
communication about past gynaecological or obstetric history, marital or
sexual problems or domestic violence. Some male partners may consider
a clinician’s examination as unacceptable particularly any discomfort
caused and may then intervene inappropriately.
An accompanying female relative may bring to the consultation her own
agenda of prejudices and fears about gynaecological examinations. It is
the view of the Medical Protection Society that a family member would
not fulfil their criteria for a chaperone, which they define as ‘someone
with nothing to gain by misrepresenting the facts’. After careful
consideration, the Working Party on Intimate Examinations of the Royal
College of Gynaecologist recommends that a chaperone should be
available to assist with gynaecological examinations irrespective of the
gender of the gynaecologist. Ideally, this assistant should be a
professional individual.
Ideally, chaperones should be another member of the clinical team, but
this is not always possible. The Ayling report states that chaperones do
not have to be health professionals but they do need to have some
training.
The report also says that family members or friends of the patients
"should not be expected to undertake any formal chaperoning role." There
is a risk of inadvertent breaches of confidentiality and embarrassment if
friends or relatives are chaperones, and they are best avoided unless there
is no alternative and postponing the examination is not possible.
If the chaperone is not someone the patient knows, it is helpful to
introduce them and explain their role.
Document chaperone’s name in the notes
The Medical Protection Society dealt with a case where a GP was accused
of making inappropriate comments while examining a young female
patient. The complaint was made months after the examination and the
doctor could not remember who had acted as chaperone, although he was
sure that he would not have conducted an intimate examination without
one as the practice had a strict policy on chaperone use. Unfortunately, he
had not made a note of the chaperone's name or position and the
complaint was upheld.
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When a chaperone is in the room you should be cautious about what you
say. It is easy to breach confidentiality unwittingly. The chaperone should
be present only for the physical examination, and you should wait until he
or she has left before discussing any aspect of the patient's care.
Regardless of whether a chaperone is present, it is wise to be careful
about making personal comments while examining a patient. A person
who is feeling embarrassed or vulnerable is more likely to misinterpret a
comment.
Communication
Communication failures often lead to complaints, and it is not unusual for
the Medical Defence Organisations to be contacted by doctors facing
serious allegations because the patient has misunderstood a justifiable
clinical examination.
A typical example is where a GP saw a teenage girl with suspected
glandular fever. Without explaining his actions he moved close and began
to feel the lymph glands in her armpits. The patient consequently
complained that the GP had fondled her breasts.
Another example is where an ophthalmologist needed to perform a
fundoscopy. He turned off the light and moved close to the patient
without explaining what he was doing. The patient thought he was going
to kiss her and complained.
Another example, is when a GP examined a patient’s breasts and while
inspecting them for differences in contour, colour and shape, the patient
thought the doctor was in fact ogling her breasts rather than examining
them and subsequently complained.
It is vital to be aware of how a patient may perceive a situation. Although
it may be a procedure that you carry out regularly, you should ensure that
you have done everything to avoid misunderstandings. Explain what the
examination entails and give the patient the opportunity to ask questions.
It is particularly important to explain your actions if you need to examine
one part of the body when the symptoms are felt in another.
In both these cases the doctors did not consider using a chaperone as they
did not think that there could be a problem. However, because they had
not explained what the examination entailed and why it was necessary the
patient misconstrued their actions and both doctors had to deal with
complaints.
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There is no absolute guarantee against an allegation of inappropriate
behaviour. Misunderstanding and maliciousness will continue to cause
problems for doctors across all specialties. However, a chaperone used
correctly and sensitively will considerably reduce the chance of facing the
nightmare of a complaint.
Requirements for intimate examinations
Patients should be provided with private, warm and comfortable changing
facilities. Provision should be made for clothing to be laid aside
appropriately and for the disposal of sanitary towels, tampons or
incontinence pads. After undressing there should be no undue delay prior
to examination. Some patients will welcome a choice between donning a
gown or continuing to wear some of their own clothes, e.g. a wide skirt
with underwear removed. Alternatively, they may welcome the
opportunity of bringing their own robe. Muslim women will wish to
continue to wear their head attire.
The woman should be given every opportunity to undress herself with
assistance from a nurse, chaperone or relative if this is necessary due to
infirmity. No assistance should be given with removing underwear unless
absolutely necessary. Every effort must be made to ensure that
gynaecological examinations take place in a closed room that cannot be
entered while the examination is in progress and that the examination is
not interrupted by phone calls or messages about other patients. In
addition to the explanation given prior to the examination, it may be
helpful to give a running commentary on what is being done during the
examination. Terms of endearment such as ‘pet’, ‘love’ or ‘dear’ should
be avoided during consultations, especially while performing pelvic
examination. It is probably better to avoid the use of first names under
these circumstances also. No remarks of a personal nature should be
made during the examination, even if they may be clinically relevant. For
example, advice about the risks of sunbathing prompted by the presence
of a deep suntan should be given after the examination has concluded.
Similarly, no comment or discussion about body weight should take place
while the woman is undressed, despite its relevance to many health
problems.
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Training for Chaperones
What is your role?
Intimate examinations are part of the day to day work of all General
Practitioners and Nurses who work in primary care. They are an area
where misunderstanding can easily arise and cause the patient anxiety or
compromise the doctor patient relationship. It is worth noting that the
GMC receives a significant number of complaints, each year, from
patients concerned about the purpose, nature and conduct of such
examinations.
A chaperone can fulfil a number of purposes. The most quoted one is
protection for the doctor and/or the patient against misunderstanding or
against false allegations of misconduct. In addition a chaperone can also
be a support to patients in this particularly vulnerable situation.
What should you expect to happen?
The clinician (and yourself) should be respectful of the individual at all
times as the patient will be in a situation where people commonly feel
vulnerable.
The purpose and nature of the examination should be clearly explained in
terms that the patient is likely to understand and permission should have
been sought to proceed. This is normally simply a question of ‘Is that
ok?’ after an explanation of what’s going to happen. This may have been
done whilst the clinician is waiting for you to come in.
In the case of children they can choose to be examined without a parent
present providing the practitioner feels the child is sufficiently mature to
make that decision. Normally we would expect the parents to be present
but there may be reasons why the child does not want them present and
it’s the doctor or nurses’ decision whether to proceed.
Sensitivity to the patient’s situation should be displayed by allowing
undressing in private and providing suitable coverings. In some practices
this is practically very difficult due to a lack of space for separate
examination rooms or even curtains in small consulting rooms. Once
undressed patients should be covered using a clean sheet, gown or a sheet
of couch roll to do this.
The amount of the patient’s body that is exposed should only be that that
is necessary to carry out the examination. It is seldom the case that an
individual should be completely stripped.
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Whilst discussion during the examination may be helpful to keep the
patient informed and to assist in the process itself the clinicians will try to
avoid unnecessary discussion to help protect the patient’s confidentiality.
Sometimes the clinician will engage in conversation to help the patient
relax but there should be no inappropriate personal comment. The
clinician and the chaperone should not engage in any discussion that is
not relevant to that patient’s examination.
Medical gloves should be worn for certain intimate examinations (e.g.
pelvic and rectal examinations). These provide a physical barrier quite
separate from fulfilling any hygiene or prevention of infection purpose.
Examinations are sometimes uncomfortable for the patient but if you
observe discomfort which you feel the clinician is not aware of you
should make them aware by asking the patient ‘Is that hurting a lot?’ or
‘Do you want the doctor/nurse to stop?’ You might mention the patient’s
discomfort to the clinician afterwards and seeing what their response is eg
‘Mrs Jones seemed to be in a lot of discomfort during the examination’. If
the clinician does not behave in an appropriate way to these comments, in
your view, you should consider informing your line manager who should
mention it to the clinician themselves or to a colleague. Although this
may sound like ‘telling tales’ it is only from the observations of
chaperones can inappropriate behaviour be tackled. Silent acceptance of
potential abuse of patients by clinicians is not acceptable.
When should you leave?
After the examination the doctor will advise the patient to get dressed. He
or she might help the patient to get up and you should help remain in the
room until the patient is covered, with their upper and lower garments on.
You may be able to make yourself feel less awkward by changing the
couch roll or by asking the doctor if you can assist in labelling specimens
or completing request forms. Unless the patient is particularly infirm or
unsteady you should not help the patient get dressed. If you do assist the
patient you should consider do you need to wash your hands afterwards?
What type of examinations may you be asked to witness and what
happens in each?
 Breast
 Female pelvic/vaginal
 Rectal
 Male genital
18
Breast examination
The following descriptions are from an online resources and
textbooks.
Experienced clinicians may do all or just parts of this.
The most difficult aspect of the clinical breast examination is considering
whether an area of concern represents a benign textural change in breast
nodularity which occurs throughout the menstrual cycle or if it
represents a malignant mass. (Rationale and Technique of Clinical
Breast Examination Karen M. Freund Medscape General
Medicine. 2000) http://www.medscape.com/viewarticle/408932_4 This is
why it is important to examine both breasts rather than just the one of
concern.
Inspection
1. Give a brief overview of examination to patient, including that both
breasts will be examined.
2. Have the patient sit on an examination couch.
3. Ask the patient to remove her clothes to her waist, assist only if
requested and/or definitely needed.
4. Have the patient relax arms to her side.
5. Examine and explain the inspection of both breasts visually for the
following:
o Approximate symmetry
o Dimpling or retraction of skin
o Swelling or discoloration
o Orange peel effect on skin
o Position of nipple
6. Observe the movement of breast tissue during the following
manoeuvres:
o Shrug shoulders with hands on hips
o Slowly raise arms above head
o Leaning forward
Palpation
1. Have the patient sit and/or lie supine/flat on the exam table.
2. Ask the patient to remove whatever is covering them and place her
hand behind her head on that side.
19
3. Begin to palpate at junction of clavicle(collar bone) and sternum
(breast bone) using the pads of the index, middle, and ring fingers.
If open sores or discharge are visible, wear gloves.
4. Press breast tissue against the chest wall in small circular motions.
Use very light pressure to assess superficial layer, moderate
pressure for middle layer and firm pressure for deep layers.
5. Palpate the breast in overlapping vertical strips/ radial or pie
fashion/ spiral technique.. Continue until you have covered the
entire breast including the axillary "tail" (into the armpit)
6. Palpate around the areola and the depression under the nipple. Only
if there is a history of nipple symptoms eg a lump or discharge
might the clinician want to examine the nipple. Often clinicians
will ask the patient to see if they can express any discharge though
a clinician may want to do this themselves. This is done by
pressing the nipple gently between thumb and index finger and
make note of any discharge. Gloves should be worn for this.
7. Lower the patient's arm and palpate for axillary (armpit) and
supraclavicular lymph nodes (behind collar bone).
8. Repeat on the other side.
9. Reassure the patient, let the patient get dressed, sit back down at
the desk and then discuss the results of the exam.
This whole examination takes 3-6 minutes to do.
20
Female Pelvic/Vaginal examination
The following is an adapted version of detailed guidance from the Royal
College of Obstetricians and Gynaecologists’ Working Group on Intimate
examinations’ report Gynaecological Examinations: Guidelines for
Specialist Practice, 2002
www.rcog.org.uk/resources/public/pdf/WP_GynaeExams4.pdf
Summary:
Verbal consent should be obtained from all women for pelvic
examinations.
Pelvic examinations should only be performed in non-English speaking
individuals with an interpreter or advocate present except in an
emergency.
A chaperone should be offered and available for all women regardless of
the clinician’s gender.
Ideally a chaperone should be a professional but a trained receptionist or
secretary is suitable instead.
Assistance with dressing should only be given if absolutely necessary.
Gloves should be worn on both hands throughout the procedure.
Remarks of a personal nature should be avoided throughout the
examination.
Any request that the procedure should be discontinued should be
respected.
Chaperones and clinicians should be alert for verbal and non-verbal signs
of distress and respond appropriately to them.
In the course of a gynaecological consultation, it is usually best if the
history is taken with only the patient present, as this will afford maximum
confidentiality and enable the doctor to gain the patient’s confidence.
Pelvic examinations, whether by male or female doctors, nurses or
midwives, should, however, normally be performed in the presence of a
female chaperone preferably unrelated to the patient. Women who require
an interpreter or who communicate using sign language will obviously
require an interpreter during both history taking and examination.
A skilled and gentle pelvic examination is a necessary and important part
of the diagnosis of most gynaecological conditions. A pelvic examination
enables a doctor to assess the vulva, the vagina, the cervix and uterus, the
ovaries and the ligamentous structures around the uterus. In symptomatic
women, appropriate digital (finger) or speculum examination can be
21
productive, for example, in assessing a patient with prolapse or in
evaluating a patient with dyspareunia (pain during intercourse) but the
value of routine examination is low and should not normally be
performed. Explanation about the contribution of the pelvic examination
towards a diagnosis in the context of the presenting complaint is an
essential part of the preamble to obtaining informed consent for
examination. Verbal consent should be obtained prior to all pelvic
examinations.
Poor self-esteem and embarrassment may deter obese women from
attending gynaecologists. In the assessment of a woman with
dyspareunia, valuable information may be obtained by assessing the
ability of digital examination to reproduce the discomfort. This is the only
situation in gynaecological practice where sexual problems should be
discussed during the examination as opposed to before and afterwards. It
should be very clear to the patient that any questions asked during the
examination are entirely technical, relating to the site and quality of the
pain, and that the woman’s feelings and sexual response are not being
discussed. Throughout the examination, the doctor should remain alert to
verbal and non-verbal indications of distress from the patient. Doctors
who are trained to combine the physical examination with an awareness
and acknowledgement of the patient’s feelings will learn more about the
patient and give rise to fewer complaints.
Speculum examinations
The reasons for carrying out a speculum examination must be clearly
explained to the patient and her verbal permission sought. As the object
of speculum examination is inspection of the vulva, vagina and cervix, it
may not necessarily be appropriate for such an examination to accompany
bimanual palpation on every occasion.
Obviously, inspection of the clitoris is indicated in some cases of vulval
cancer, female genital mutilation and congenital adrenal hyperplasia. In
the course of routine pelvic examination, however, care should be taken
to avoid digital contact with the clitoris.
The patient will be asked to lie in an appropriate position for the
examination. Usually the dorsal position is chosen for examination with a
Cusco speculum (patient lying flat on back with legs bent up). The Sims
or left-lateral position is used for Sims speculum examination (patient
lying on their left side, back towards the doctor who lifts the right leg to
insert the speculum). Sometimes pelvic examination in the semi-sitting
position provokes less anxiety than examination in the supine position.
Whatever position is used, the patient must be made comfortable and
22
provided with as much covering as feasible. It may be easier to preserve
an appropriate degree of modesty with the patient lying on her side than
on her back, but many women find an unseen approach from the rear
most alarming and are less certain where the finger or speculum is going.
Whilst in specialist practice it may be helpful in certain clinical scenarios
to examine the patient in a standing position in general practice unless the
doctor has particular expertise in gynaecology this would not normally be
appropriate. Careful thought should be given to the necessity for this and
to its appropriate conduct to minimise the additional embarrassment it is
likely to induce.
Vaginal specula
The Cusco speculum and the Sims speculum are the most commonly
used, the Cusco being particularly appropriate for cervical inspection and
the Sims if a speculum examination is being performed as part of a full
gynaecological examination in cases of suspected uterovaginal prolapse
and urinary fistula.
Cusco Speculum Simms Speculum
Specula should be warm but not excessively so. If they are of the metal
variety and kept following sterilisation on a cloth over a radiator, held
under a warm tap for a few moments or held in the doctor’s gloved hand
prior to insertion, the degree of warming will usually be adequate. The
temperature of the speculum should be checked after any procedures
aimed at warming it to ensure it has not become excessively hot. It is
essential that an appropriate size of speculum be used and this may mean
that a single-finger assessment of the introitus will need to be performed
prior to selecting a speculum. This is particularly important in postmenopausal women or post-operative patients in whom there may be
some narrowing of the introitus. A small speculum may be required in the
nulliparous or virginal woman, although such examination is rarely
indicated in a virgin. Specula appear to some patients to be large,
cumbersome and potentially painful instruments – they must be used with
gentleness and sensitivity. There is no excuse for fumbling with the
23
instruments. If the examiner is relatively inexperienced in the use of
specula, it is essential that he or she practises assembling the instruments
prior to insertion rather than subsequently fumbling and causing distress.
Some of the disposable plastic devices have a noisy ratchet device which
some patients might find unnerving – the ratchet strip can be broken and
the speculum used without it if need be. The use of a water-based, nonsticky lubricant such as one of the proprietary clear gels is advisable.
Performing a vaginal speculum examination
Gloves should be worn on both hands by the examining doctor for all
vaginal and speculum examinations.
The patient must be told about each manoeuvre prior to it being
undertaken. When she is in an appropriate position and is comfortable,
she should be told that the examiner is going to examine the vulva,
separate the labia and insert the speculum. It should be inserted to its full
length and then gently opened, enabling inspection of the cervix. If the
cervix is pointing anteriorly (forwards), such as would commonly be the
case with a retroverted (tilted backwards) uterus, or deviated to one or
other side, a certain amount of adjustment of the position of the blades
may be necessary and this should be carried out with great gentleness.
Sometimes it will be necessary to use a blunt instrument such as a
sponge-holding forceps to gently move the cervix clear of the tips of the
speculum blades if an adequate view is to be obtained. Sometimes the
speculum is introduced too far and is in either the anterior or posterior
fornix (the space in front of and behind the cervix). In this case, the
cervix will only appear if the speculum is gently opened and withdrawn.
The examination may now proceed, with the taking of swabs from the
posterior vaginal fornix or the endocervical canal, if appropriate, and the
taking of a cervical smear, should this be indicated. It may be necessary
to mop secretions from the cervix in order to obtain a good view of its
epithelium. It is important that the patient be told of all these manoeuvres
before they are carried out in understandable and non-patronising
language. When the operator is happy with the information obtained from
speculum inspection of the cervix, the instrument will be slowly and
gently withdrawn and the vaginal walls inspected during its withdrawal.
There is a danger of trapping the cervix between the blades of the
speculum if it is not held open a little as it is withdrawn. When taking
cervical the patient must be warned in advance about what the operator is
about to do, as some discomfort can result, especially if an endocervical
brush is used. She should also be told that there may be some bleeding
following the taking of a smear and reassured that this is not usually of
any clinical significance.
24
Bimanual abdominal/vaginal examination
This is considered by most women to be the most intimate of
examinations and its use should be restricted to occasions when it is
necessary that such an examination be performed. There are occasions
when a speculum examination alone may be carried out but, in a woman
with gynaecological symptoms, the two should usually be combined. In
order to minimise the inevitable discomfort of bimanual examination and
to obtain the most information from the procedure, it is important that the
bladder is empty. Gynaecologists should be trained to perform bimanual
examination in both the left lateral (lying on left side) and the dorsal
(lying flat on back) position, in order to cater for the patient’s personal
preference though most GPs would normally examine the patient in a
dorsal position. Bearing in mind that it is the abdominal hand that does
most of the palpating, it is obviously necessary for as much abdominalwall relaxation to be obtained as is possible. Some patients find it
extremely difficult to relax when being subjected to what for them is a
most embarrassing procedure. Every effort should be directed to gain the
patient’s confidence and reduce her anxiety. It is important that
abdominal palpation as part of the bimanual examination procedure
commences with the ‘abdominal’ hand relatively high on the abdominal
wall, as it would otherwise be possible to miss substantial masses arising
from the pelvis. Feeling the outline of the uterus is best achieved by using
the vaginal finger or fingers to elevate and bring forward the uterus by
means of gently exerting pressure on or behind the cervix. It is not always
mandatory to insert more than one finger, especially in very slim patients.
The examination is to accurately and consistently delineate the uterine
size, shape and contour, especially if the uterus is retroverted. In addition
to these features, it should be possible for the examiner to form an
impression of the degree of mobility or fixity of the uterus. Following
examination of the uterus, the adnexa are palpated bimanually. Normalsized ovaries may not be palpable, especially in the overweight or
postmenopausal patient. The right ovary is more readily palpable than the
left, which may be difficult to feel if it is lying behind the bowel,
particularly if the bowel is loaded.
Clinical evidence of tumours may also be detected, together with
evidence of ‘cervical excitation pain’, produced by gently moving the
cervix and putting the adnexal structures slightly on the stretch. All these
procedures must be carried out with extreme gentleness but even if this is
achieved and even if a major degree of patient confidence is also
obtained, there will inevitably be some discomfort associated with
bimanual palpation. The examination may also be uninformative,
particularly if the patient is obese or very tense and anxious. At the
25
conclusion of speculum or bimanual examination, the patient should be
given some tissue with which to remove any remaining lubricating gel.
Ideally, washing facilities and a mirror should be provided so that the
patient can dress in comfort and privacy. Thereafter she should be told of
the examiner’s findings, once she is seated back in the consulting room.
Although the patient, particularly if elderly, may appreciate the presence
or help of a nurse or chaperone while she is dressing, it is generally
preferable if the consultation subsequent to examination is conducted
with only the doctor and patient present, for reasons of confidentiality,
unless of course the patient wishes otherwise or needs the services of an
interpreter or sign language.
A pelvic examination takes between 5-10 minutes to do plus 5 minutes to
take a smear and swabs.
26
Rectal examination
The following descriptions are edited from Macleods Clinical
Examination. Experienced clinicians may do all or just parts of this.
Left lateral position for rectal
examination











Wear gloves
Lubricate index finger.
Throughout examination be alert for the patient’s discomfort.
Position the patient in the left lateral position
Reassure the patient that the examination may be uncomfortable
but should not be painful.
Inspect the anus for haemorrhoids and anal tears
Insert finger slowly, assessing external sphincter tone as enter.
Rotate finger, palpating along anterior, left, posterior, right walls.
Ask patient to squeeze the examining finger.
Withdraw finger, inspect for stool colour and presence of blood /
mucus
Wipe lubricant off pt.
27
Male Genital Examination
The following descriptions are edited from an online resources and
medical textbooks
Experienced clinicians may do all or just parts of this.
Penis

Gloves on.
 Retract foreskin if indicated.
 Rashes, ulcerations, swellings, lesions, warts.
 Urethral meatus:
• Meatus is patent
• Meatus is in normal location.
• No extra openings (hypospadias).
 Look for discharge:
• Bloody.
• Purulent.
If discharge, compress penis to express some for swab and culture
Scrotum: inspect
 Gloves on
 Note size and symmetry
 Look for rashes, ulcerations, swellings, lesions.
Scrotum: palpate
 Similar size, consistency for R and L.
 Smoothness, firmness.
 Absent testicle causes:
• Undescended [look in inguinal canal].
• Surgical removal.
 Masses – palpate around testes to see if testes is separately
identifiable and whether an inguinal hernia is likely if not
Scrotum: translucency
 Performed if a mass was palpated.
 Turn off lights.
 Hold light up to posterior of swelling, and test for translucency:
• Opaque: solid mass.
• Translucent: cystic.
 Examine whether separate from the testis.
28
Lepton & Kirkheaton Surgeries
Chaperones
Lepton & Kirkheaton Surgeries are committed to providing a
safe and comfortable environment where patients and staff can
be confident that “Best Practice” guidance as recommended by
the General Medical Council of the United Kingdom is being
followed at all times and the safety of everyone is of paramount
importance.
All patients are entitled to have a chaperone present for any
consultation, examination or procedure where they feel one is
required. A chaperone is often used for intimate examinations to
act as a witness, support and safeguard for both the patient and
the health care professional.
The surgery will endeavour to provide a chaperone at the time of
request; however, occasionally it may be necessary to
reschedule your appointment to arrange a chaperone.
Wherever possible we would ask you to make this request at the
time of booking an appointment so that arrangement can be
made and your appointment is not delayed in any way.
Your healthcare professional may require a chaperone to be
present for certain consultations in accordance with our
Chaperone Policy.
If you would like more information on the use of Chaperones
please see our website www.lepton-kirkheatonsurgeries.nhs.uk
or contact our Practice Manager to see the full Chaperone Policy
reference document. Thank you.
29
References
 GMC Intimate examinations and chaperones April 2013
http://www.gmcuk.org/guidance/ethical_guidance/21168.asp
 The Medical Protection Society Factsheets- Chaperones
England July 2014
http://www.medicalprotection.org/uk/englandfactsheets/chaperones
 Rationale and Technique of Clinical Breast Examination
Karen M. Freund Medscape General Medicine. 2000
http://www.medscape.com/viewarticle/408932_4
 Gynaecological Examinations: Guidelines for Specialist
Practice, © Royal College of Obstetricians and
Gynaecologists 2002
http://www.rcog.org.uk/resources/public/pdf/WP_GynaeE
xams4.pdf
 Douglas, G, Nicol, F, Robertson, C. Macleod's clinical
examination. 12th edn. Edinburgh: Churchill Livingstone
Elsevier. 2009
30